Consent for Therapy

You will be asked to sign the form below at your initial session at Mind Body Well. please familiarise yourself with the terms.


In order to provide quality assessment and therapeutic services, Consultants at Mind Body Well will collect and record personal information relevant to your situation. ‘Consultants’ referred to in this document include Psychologists and Dietitians providing professional services at Mind Body Well.

Purpose of collecting and holding information

Any personal information gathered as part of your assessment and treatment process will be kept securely and, in the interests of your privacy, used only by your Consultant and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, assisting your Consultant to provide a relevant and informed service to you.

Access to client information

You are entitled to access your personal information kept on file, unless relevant legislation states otherwise. If you require access to your information please discuss this with your Consultant.

Disclosure of personal information

Personal information gathered by your Consultant during the provision of services is considered confidential and will not be disclosed to another party except when:

  • your prior approval has been obtained to:
  • a)    provide a written report to another professional or agency. eg. a Doctor or a Lawyer; or
  • b)    discuss your care with another person, eg. a Parent, Employer or Health Care Provider; or
  • it is subpoenaed by a court; or
  • failure to disclose the information would in the reasonable belief of your Consultant place you or another person at serious risk of harm; or
  • disclosure is otherwise required by law.


Confirmation of Consent

I ________________________________________________________________

have read and understood this Consent Form, and I agree to the above conditions for the services provided by:



Client signature     _________________________________________________     

Date                           /