Service Provision/Agreement for Individual & Group Sessions

Therapeutic Service

As part of providing a therapeutic service to you, Mindscape Therapy Pty Ltd 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.

This collection of personal information will be a necessary part of the therapeutic assessment and treatment that is conducted. Your informed consent will be obtained before any treatment or procedure is initiated and you may withdraw from treatment at any time without prejudice.


Your personal information is gathered as part of your assessment and treatment. All of this is kept securely and, in the interests of your privacy, used only by your therapist and the authorised personnel of the practice (as necessary). We would like to emphasize that your privacy and the information that you provide is always protected. All our therapists are registered with their professional regulatory bodies and it is a requirement that all therapists follow strict guidelines for professional conduct that is in line with associated Codes of Ethics.

Your personal information is retained in order to document what happens during sessions and enables the therapist to provide a relevant and informed therapeutic service to you. You are entitled to access your personal information kept on file at any time. Should you wish to see the information kept on your client records, please discuss this with your therapist.

Limits to confidentiality

All personal information gathered by the therapist during the provision of the therapeutic service will remain confidential except when:

  1. It is subpoenaed by a court; or
  2. Failure to disclose the information would in the reasonable belief of the Mindscape Therapy Pty Ltd place you or another person at serious risk to life, health or safety; or
  3. Your prior approval has been obtained to:
  4. Provide a written report to another professional or agency. e.g. GP, school or a lawyer; or
  5. Discuss the material with another person, eg. a parent, employer or health provider; or
  6. Disclose the information in another way; or
  7. You would reasonably expect your personal information to be disclosed 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; or
  8. Disclosure is otherwise required or authorised by law; or
  9. When consulting with colleagues, or in the course of supervision, your therapist will be required to conceal your identity and any associated parties involved; and to preserve your privacy at the utmost professional manner in accordance with the Code of Ethics.

Consequence of not providing personal information

If you do not wish for your personal information to be collected in a way anticipated by this consent form, Mindscape Therapy Pty Ltd may not be able to provide the therapeutic service to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable for Mindscape Therapy Pty Ltd to deal with you or if Mindscape Therapy Pty Ltd 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, however, if the therapist at Mindscape Therapy Pty Ltd agrees to you being anonymous or using a pseudonym, you must pay consultation fees at the time of the appointment.

Cancellation Policy

To ensure that Mindscape Therapy Pty Ltd provides the highest quality of care to our clients, please give a minimum of 24 hours’ notice if you are unable to attend your scheduled appointment. Otherwise, you will be charged a late cancellation/ non-attendance fee. This fee must be paid in full prior to the commencement of your next session at Mindscape Therapy Pty Ltd.

Your cancellation notice would be much appreciated, as this can enable us to provide services to other clients who may need an urgent appointment.