Consent Form

Psychological/Behaviour Support service

As part of providing a Psychological/Behaviour Support service to you, Jodie Logan Behaviour Support and Therapeutic Services needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history, and other relevant information as part of providing Psychological/Behaviour Support services to you.

This collection of personal information will be a necessary part of the Psychological/Behaviour Support assessment and treatment that is conducted.

Authority to collect, hold, use, and disclose participant information

Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and provision of supports, is kept securely and, in the interests of your privacy, used only by your Psychologist/Behaviour Support Practitioner and the authorised personnel of the practice (as necessary). Your personal information is retained to document what happens during sessions and enables the Psychologist/Behaviour Support Practitioner to provide a relevant and informed Psychological/Behaviour Support services to you. A more detailed description is provided in the practice’s “Privacy policy for management of personal information”, which can be obtained by contacting Jodie Logan (AHPRA Registration: PSY0001756127). The Privacy Policy contains information about how to access and seek correction of your personal information, and how to lodge a complaint about our management of your personal information.

Personal information collection, holding, use and disclosure of personal information by this organisation is protected by the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) (Privacy Act). Personal information is any information or an opinion that identifies you or could identify you and includes information about your health.

The purpose for collecting personal information from you is to:

  • provide services, including planning, coordinating, funding, implementing, monitoring, and reviewing our services
  • report to NDIS, government or other funding bodies of how funding is serviced by us,
  • responding to your feedbacks, and
  • responding to your queries.

*Please note that we are required to release information about service users (without identifying you by full name or address) to the Disability Services Commission and the Australian Institute of Health and Welfare to ensure statistics about disability services and their participants to be compiled. The information will be kept confidential. This information is used for statistical purposes only and will not be used to affect your entitlements or your access to services. As a user of National Disability Agreement services, you have the right to access your own files and to update or correct information included in the Disability Services National Minimum Data Set collection.

This organisation will not disclose/use information about you for any secondary purpose unless:

  • You have consented to the use or disclosure; or
  • You would reasonably expect us to use or disclose the information for the secondary purpose
    as it is directly related to the primary purpose; or
  • The use or disclosure of the information is required or authorised by or under an Australian law or a court/tribunal order; or
  • Our organisation reasonably believes the use or disclosure is necessary to lessen or prevent a serious threat to life, health or safety of an individual or to public health and safety; or
  • Our Organisation has reason to suspect an individual may have done something unlawful or engaged in serious misconduct that relates to organisational functions or activities;
  • Our organisation reasonably believes that the use or disclosure is reasonably necessary to assist another person to locate a person reported as missing.

Consequence of not providing personal information

If you do not wish for your personal information to be collected in a way anticipated by this letter or the Privacy Policy, Jodie Logan Behaviour Supports and Therapeutic Services may not be in a position to provide the Psychological/Behaviour Support services to you. You may request to be anonymous or to use a pseudonym unless it is impracticable for Jodie Logan Behaviour Support and Therapeutic Services to deal with you or if Jodie Logan Behaviour Support and Therapeutic Services is required or authorised by law to deal with identified individuals. In most cases it will not be possible for you to be anonymous or to use a pseudonym.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The Psychologist/Behaviour Support Practitioner may discuss with you different possible forms of access.

Disclosure of personal information

All personal information gathered by the Psychologist/Behaviour Support Practitioner during the provision of the Psychological/Behaviour Support services will remain confidential except when:

  1. . it is subpoenaed by a court, or disclosure is otherwise required or authorised by law; or
  2. failure to disclose the information would in the reasonable belief of Jodie Logan Behaviour Support and Therapeutic Services would place you or another person at serious risk to life, health or safety; or
  3. your prior approval has been obtained to
    1. provide a written report to another professional or agency. e.g., a GP or a lawyer; or
    2. discuss the material with another person, e.g., a parent, employer, health provider or thirdparty funder; or
    3. disclose the information in another way; or
    4. disclose to another professional or agency (e.g., your GP) and disclosure of your personal
      information to that third party is for a purpose which is directly related to the primary purpose
      for which your personal information was collected.

Your personal information is not disclosed to overseas recipients, unless you consent, or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented, or disclosed for any other purpose.

If unauthorised access, disclosure or loss of a client’s personal information occurs, Jodie Logan Behaviour Support and Therapeutic Services will activate its data breach plan and use all reasonable endeavours to minimise any risk of consequential serious harm.


The cost of supports is set out in the Service Agreement.

Audit Process
Cancellation Policy

If, for some reason you need to cancel or postpone your appointment, please give at least 24 hours’ notice, otherwise you may be charged the cost for the session.


I agree to the above conditions for the Psychological/Behaviour Support service provided by Jodie Logan Behaviour Support and Therapeutic Services.

Please note: If, after reading this form you are at all unclear about any of the information provided, please contact the Jodie Logan on 0419809794 prior to your appointment.

This field is for validation purposes and should be left unchanged.

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