Request for service application

Please read the below information carefully.

I wish to receive, or for my child to receive, speech pathology assessment or treatment at the La Trobe Communication Clinic at La Trobe University. I understand and agree in relation to my attendance that:

1. sessions will be provided by qualified staff and supervised students of the University
2. sessions may be observed by staff or students of the University for instruction or examination purposes
3. sessions may, with my prior consent, be observed by certain persons authorised by the University for professional training and development purposes
4. the program of treatment may involve any or all of the following:
• Diagnostic testing and treatment of my/my child’s communication, and/or swallowing
• Audio or video recording of me/my child to assist with management of my/my child’s condition
• Audio or video recording of me/my child to assist with clinical training of the speech pathologist.

This Additional Consent relates to the policies of the La Trobe Communication Clinic in the provision of services using a telehealth platform (e.g. telephone or online telehealth platform). The information provided here should be read alongside the following La Trobe Communication Clinic documentation:

• Telehealth brochure
• Your Rights and Responsibilities brochure

Telehealth Services in the Clinic

The clinician (Speech Pathologist or Student Speech Pathologist) may provide telehealth speech pathology services using the telephone or an online communication platform (e.g., Zoom) as agreed by the clinician and the client.

Confidentiality and Risks

• Telehealth is subject to the Privacy Act 1988 and must comply with obligations related to the collection, use and disclosure of personal information. The clinicians must maintain confidentiality and privacy standards during sessions, and in creating,keeping, and transmitting records.
• At times, audio and video recordings of sessions may be taken to support the clinician’s work and/or training, as might occur in a face-to-face consultation. Any recordings taken will be saved on a secure drive accessible only to Clinic personnel. You are not permitted to video or audio record the consultation, unless your speech pathologist gives you permission to do so.
• While the clinicians are obligated to meetstandardsto protect your privacy and security, use of Online communication platforms for telehealth, may increase exposure to hacking and other Online risks; as with all Online activities, there is no guarantee of complete privacy and security protection. You may decrease the risk by using a secure Internet connection, meeting with the speech pathologist from a private location, and only communicating using secure channels.
• For clients under 18 years, an adult must be present for the whole session sitting next to and supporting the child through the activities.
• If there is a disruption to services or technical difficulties with the online communication platform, the clinician will ring the client via telephone to discuss how to proceed with the session. If reconnection is not possible within 10 minutes, the client will be sent an email to reschedule the session.
• In case of an emergency, clients will be asked to provide information about their current location, and the contact details of two people. This allows the clinician to respond appropriately if there are concerns about the client’s wellbeing.

Informed consent for Telehealth:

There are a few important principles related to informed consent:

• You must be given relevant information. Ask the clinician if you have questions about telehealth and the services offered.
• You have the right to understand the information. Ask the clinician if you do not understand.
• You have the right to choose. If you do not agree to telehealth, you may refuse to participate. You may agree to or refuse specific activities and procedures. You can change your mind about the use of telehealth at any time, without affecting your right to future care or treatment. You may give your consent using this form. You may also give consent or change your mind by telling the clinician. Consent and refusal that you give verbally will be documented by the clinician. If you refuse or change your mind about telehealth services, your clinician will discuss any other options with you. The clinician may or may not be able to offer alternative services.
• Telehealth may not be a suitable service for you. If the clinician believes that telehealth is no longer appropriate for a client’s needs, the clinician may suspend treatment until in-person sessions can be resumed, or the clinician may refer the client to a more appropriate service.

I agree to the Clinic’s fee and cancellation policy as follows:

• fees for each session will be charged in accordance with the then-current Fee Schedule published on our Comminication Clinic page (available at any time on request)
• unless otherwise agreed, session fees must be paid in full at the time of attendance
• cancellations must be notified at least 24 hours prior to the scheduled session
• cancellations with less than 24 hours’ notice will incur a charge of 50% of the session fee
• full session fees will be charged for failure to attend a scheduled session without notice of cancellation
• Trans and Gender Diverse Clinic - failure to attend a session without notice or cancelling with less than 24 hours’ notice will incur a $10 cancellation charge
• multiple cancellations or failure to attend may result in discharge from the Clinic.

La Trobe University respects the privacy of your personal information and health information. Information collected in this form will be used for purposes related to this form in accordance with the University’s privacy policies. A copy of the clinic’s privacy collection notice is available on our Your rights and responsibilities document or upon request.