Individual 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 with any part of this form, please do not complete it or submit payment. Jen cannot provide a service if you do not agree to these terms. Please take the time to fully understand what you are agreeing to; there is no rush or pressure to book in.

1. 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

2. NovoNote Explanatory Statement & Consent

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

Purpose of the automated note taker: The use of an AI-enhanced note taker was adopted to enable us to focus entirely on communication and your care during sessions, rather than being distracted by manual note-taking.
What We Save: As a healthcare provider, we keep notes of our contact with you to help us serve you better. NovoNote helps by transcribing the session and then providing a summary. Typically, the transcript of the session is deleted and does not make up part of your patient file, while the summary is saved. Audio of the session is never saved.
Compliance and Security: NovoNote complies with the Australian Privacy Principles, AHPRA standards, and HIPAA guidelines. It adheres to industry encryption and security protocols on a secure server in Australia. Your data does not contribute to training AI models.

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

3. Mandatory Intake Acknowledgments

Age Requirement: I confirm that I am over the age of 18 years.

Booking Identity: I confirm that I am the person who is to be assessed, and that this booking is in my full legal name, and that the contact details provided are my own. I understand that bookings cannot be made on behalf of another person.

Nature & Scope of Service: I am aware that this service provides a lower-cost, online assessment for adult patients curious about potential neurodivergence. I understand it is not a multi-hour in-person assessment, that Jen is a Psychologist (not a medical doctor), and that psychologists cannot prescribe medication.

No Guarantee of External Acceptance: I understand that an assessment does not automatically guarantee medication from a medical doctor, nor does it guarantee acceptance, funding, or approval from the NDIS, private health insurance, Disability Support Pension, or any other agency.

Diagnostic Outcomes & Finality: I understand that I may not meet the diagnostic criteria for Autism or ADHD through this assessment, and I acknowledge that all assessment outcomes and diagnoses made by Jen are final.

Non-Refundable Deposit: I am aware that I must provide a 50% deposit at the time of booking to secure my appointment. I acknowledge that this deposit is non-refundable as administrative setups, test distribution, and file reviews begin immediately.

Pre-Interview Requirements & Payment (72-Hour Rule):

Before my clinical interview:
I am aware that, 72 hours prior to the scheduled interview:

The remaining 50% balance must be paid via my stored card on Zanda; and

I must complete and submit all required diagnostic questionnaires and NovoPsych forms
If payment is not made in full at least 72 hours prior to the appointment, or I do not submit the questionnaires and forms by that time, my appointment will be automatically postponed and a 50% cancellation/rescheduling fee will apply.

Report Delivery: I understand that reports take time to compile (typically up to 6 to 12 weeks, and up to 3 months).

Revision Policy: I acknowledge that reports and receipts cannot be modified, rewritten, or tailored, including to meet external agency requirements. Reports will only be edited to correct verified factual/administrative errors (e.g., misspelling of my legal name), which I must notify immediately by email.

Raw Data & Admin Fees: I understand that raw test data, scoring sheets, and test interpretation mechanics will not be released under any circumstances. I am aware that requesting copies of my records will incur a $50 administrative fee.

Follow-Up Consultation Rules: I understand that optional paid follow-up consultations are strictly for discussing the written conclusions in my report and what they mean. I acknowledge that follow-up sessions cannot be used to request report text changes, alter diagnoses, or access raw test data.

Location Requirement: I confirm that I am residing and physically accessing this service within Australia.

Respect & Conduct Policy: I agree to conduct all interactions with professionalism and respect. I understand that any abusive language, bullying, threats, or harassment toward staff may lead to immediate service termination and file closure without a refund.

Communication: I agree to email and SMS updates

Neuro-Affirming Counselling Services & Client Agreement

Please review each section below and tick the corresponding boxes to confirm your understanding and agreement.

1. Scope of Counselling Services

I understand that the counselling provided is a neuro-affirming service.

This service focuses on practical, personalized support tailored to work with my brain—including executive functioning, routines, life admin, overwhelm, communication, and self-understanding.
It is not aimed at changing who I am or forcing me to fit a particular mould.
Crisis & Emergency Notice: I understand that this counselling service is not an emergency or crisis support service. If I am in crisis or at risk of harm, I agree to contact emergency services (000 in Australia), call Lifeline (13 11 14), or present to the nearest emergency department.

2. Bookings, Payments & Cancellations

I agree to the practice booking, fee, and cancellation policy:

Payment: Full payment is required at the time of booking to confirm my appointment.
Rescheduling: I may reschedule my session once without penalty by providing at least 72 hours (3 days) notice prior to the scheduled time.
Late Cancellations & Non-Attendance: Cancellations made with less than 72 hours' notice or unattended sessions ("no-shows") will be charged in full and are non-refundable.
Late Arrivals: If I arrive late, my session will still conclude at the scheduled end time and the full fee will apply.

3. Telehealth Requirements

I understand my responsibilities for telehealth appointments:

I am responsible for ensuring access to a private, quiet space and a reliable internet connection for my session.
Technical issues on my end during a scheduled session will be treated as session attendance. If technical issues arise on the practitioner's side, the session will be rescheduled or refunded.

4. Privacy, Confidentiality & Service Expectations

I acknowledge and consent to the privacy and professional boundaries policy:

Confidentiality: My personal information and session content will remain confidential and handled in accordance with the Privacy Act 1988 (Cth).
Limits of Confidentiality: Confidentiality may be broken without my consent if there is a serious risk of harm to myself or others, if required by law/court order, or under mandatory reporting guidelines. Information may also be shared internally within the practice for quality care administration.
Mutual Respect & Readiness: I agree to engage respectfully with practitioners and staff, and to attend sessions free from the influence of alcohol or non-prescribed substances that could impair participation.

Client Acknowledgement & Digital Signature

By ticking this box and submitting this form, I confirm that I have read, understood, and agree to all the terms, policies, and neuro-affirming service guidelines outlined above.

Client Full Name:

Date: