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Please COMPLETE THE Service agreement and parent consent form BELOW

Service agreement and parent consent form

Service agreement and parent consent form

  1. A professional service may include:

    1. Administration of formal tests considered relevant to diagnosis and supportive intervention

    2. Therapy sessions

    3. Communication of your child’s learning / developmental concerns with teaching, allied health, or medical professionals

    4. Tele- or videoconference with teaching professionals

    5. Childcare / School observation

    6. Formal report.

  1. Deberea will need to collect and record personal information that is relevant to the referral concerns.  This will involve written and electronic records and may involve video or audio recordings of your child for use in preparing consultations, reports, and recommendations with parents, educational personnel and other professionals. The confidentiality of these records will be upheld at all times, and no use will be made of this material for any purpose other than those explicitly stipulated above.

  2. Deberea may contact other professionals who are or have been directly concerned with the care or education of your child to seek information about your child’s abilities and performance that may be relevant to the requested service. This information may include written accounts or reports and is sought with the intent of supporting your child’s learning and development. Parental permission for Release of Information will be sought prior to contacting professionals.

  3. Confidentiality:  All personal information gathered during the provision of services will remain confidential and secure. Deberea will obtain your approval -

    1. to discuss your child’s developmental concerns with teaching or medical professionals, and

    2. to provide a written report to another professional or agency (e.g., your child’s school) if required.
      Please note that personal information cannot remain confidential if the information is subpoenaed by a court, or failure to disclose the information would place your child or another person at risk.

  4. A fee for service is payable at the close of each consultation. EFTPOS and HICAPS are available.

  5. Deberea reserves the right to charge in full for appointments not attended or where less than one day’s notice of non-attendance is given.  In the event of illness or unforeseen circumstances, every effort will be made to reschedule the appointment.

  6. It is the policy of Developmental Support for Children that a parent or guardian accompany and supervise their children while in reception.  Your child, or his or her siblings, must not be without adult supervision when parents are in consultation with Deberea. Therefore, parents are requested to make suitable arrangement for the care or supervision of their children when undertaking a parent consultation.