Client Consent Form

All new clients must complete this consent form and agree to the Terms and Conditions of the Service at the end of the form. If you feel unsure, confused or do not agree, please do not complete this consent form. Please note, Jen can not provide you with a service if this is the case. Please take the time to fully understand what you are agreeing to. There is no rush or pressure to book in.

Personal Information

First Name *

Last Name *

Phone number *

Email Address *

Date of birth *

What is your address? *

Street address *

City *

State *

Postcode *

Emergency contact name *

Emergency contact phone number *

Comments

Novo Note Taker

Clinicians at our clinic are using NovoNote, an automated tool designed to assist clinicians with taking session notes.

Below is an explanatory statement about the technology.

Purpose of the automated note taker

The use of an AI enhanced note taker was adopted to enable us to focus more on communication and your care during sessions, rather than being distracted by manual note-taking.

What We Saved

As a healthcare provider, we keep notes of our contact with you to help us serve you better.

Our AI note taker, NovoNote, helps by transcribing the session and then providing a summary of that session.

Typically, the transcript of the session will be deleted and will not make up part of your patient file, while the summary is saved as part of your file. Audio of the session is never saved.

Compliance And Security

NovoNote complies with the Australian Privacy Principles and is compliant with AHPRA and HIPAA standards. It adheres to industry encryption and security protocols. NovoNote operates on a secure server in Australia and your data does not contribute to training AI models. For more detailed information on the security measures and protocols of NovoNote, please visit the security page: NovoPsych.com.au/NovoNote_Security

Consent

I agree to the audio of my session being processed into a transcription by Novo Note for the purpose of creating session summaries. *

I have taken the time to fully understand this assessment process, what it involves and have had the opportunity to ask any questions. *

I understand that Jen is a psychologist (not a medical doctor) and does not provide medication *

I understand that in order to secure my booking, I need to provide a 50% deposit. This is non-refundable if I cancel less than 48 hours before my appointment or if I do not show up (15 minutes or more late). The remaining 50% will be deducted from my stored card on Zanda and processed on the day of my appointment. *

I understand that I may not meet diagnostic criteria for autism or ADHD though this assessment. *

I understand that all assessments and diagnoses are final from Jen *

I understand that my assessment does NOT automatically guarantee medication from a doctor; NDIS, government or any other agency program acceptance or approval *

I understand that comprehensive or summary report takes time to complete and will be available as soon as possible. This may take up to six weeks. If I need it sooner or it has been longer than 6 weeks, I will send Jen a follow up email once. *

I live in Australia and am accessing this service in Australia *

At Neurodiverse, we are committed to fostering a respectful and inclusive environment. We do not condone bullying, intimidation, or threats in any form towards our staff, and we strive to ensure all interactions are conducted with professionalism and kindness. *

I have read, understood and agree to the Terms and Conditions of the Service *