Patient Identification & Consent Form (Page 2 of 3) in pdf

Dr Mathew McCauley, Consultant Clinical Psychologist

Suite 13, Blackrock Clinic, Rock Road, Blackrock, County Dublin, Ireland

Tel: 01-2064217; Fax: 01-2780354

Patients are often unsure what to expect when visiting a clinical psychologist. You are encouraged to consider the following points

regarding mental health care, and to discuss them with Dr McCauley if you wish.

What You Can Expect From Your Psychologist. You can expect the attention, respect, and best professional efforts of Dr

McCauley. Dr McCauley will treat you as a responsible individual and will expect you to take an active part in your treatment. You

should also expect to take part in the treatment decisions. You should understand the goals and direction therapy is taking, and if you

do not understand, you should ask. If you desire a different clinician or a "second opinion," please discuss this with Dr McCauley.

Your Responsibilities. If you should need to cancel your appointment, please do so at least two business days in advance of the

scheduled session, so the time can be offered to someone else. Non-attendance or appointments cancelled in less than two business

days of the scheduled interview will be charged at the standard rate. *For mental health emergencies, your nearest Accident and

Emergency Department will be able to assist.

Privacy Issues. Before initiating a professional evaluation or treatment relationship with Dr McCauley, we want you to know

about privacy ground rules. Dr McCauley provides services that are consistent with patient privacy standards outlined by the

American Psychological Association, Psychological Society of Ireland, British Psychological Society, and Health Insurance

Portability and Accountability Act (HIPPA). Generally, information discussed during the evaluation and treatment sessions is

confidential and may not ordinarily be revealed to anyone outside the clinic without your consent. Under some limited circumstances,

information may be released without your permission. These are discussed below.

Records of Your Care. Every visit with Dr McCauley is documented and such entries contain only pertinent information

relating to your care, in order to protect your privacy. These chart entries are stored electronically and at times, in hard copy at the

Blackrock Clinic. If you have been referred to Dr McCauley by another clinician (e.g. psychiatrist), then a brief summary of your care

is communicated to your referrer. Liaison with your GP is also standard practice, even if you have self-referred to the clinic, as this

helps to facilitate continuity of care. If Dr McCauley refers you to another mental health or medical service, then a referral letter is

constructed and passed to the new provider. In this regard, it is important to note that aside from acute emergencies, your written

consent will be obtained before such information is released. Finally, other than when ordered to do so by a judge, Dr McCauley will

obtain your written consent, before releasing pertinent information from your records for legal purposes.

Disclosure Policy. The privacy of your mental health records is protected by the legal and professional-regulatory standards of

Dr McCauley’s practice. Under these rules, Dr McCauley may release your records without your consent under limited circumstances.

Such situations include: Danger to Self or Others. Clinical psychologists’ must take steps to protect individuals from harm when the

patient presents a serious threat to the life or safety of self or others. Psychologists’ must report explicit threats to kill or seriously

injure a clearly identified or reasonably identifiable person, or to destroy property under circumstances likely to lead to serious bodily

injury or death.

Supervision Requirements: Clinical psychologists are required by their professional regulatory body to undergo regular clinical

supervision with a psychologist peer. Clinical supervision may include a discussion of your case or treatment plan, or a review of

psychological test results. Your identifiable details are not disclosed to the supervisor and supervisors’ are held to the same level of

confidentiality as your provider. Any request to record your session for supervision purposes requires additional written consent by

you.

Consent: I consent to be assessed and treated as appropriate by Dr McCauley. I acknowledge that I have had the confidentiality

limitations explained to me. I have read and understand the above policies. I understand that I have a right to have any of the above

policies explained further to me and that a copy of this information sheet will be given to me at my request. A photocopy of any

signed form will be considered as an original copy. I understand that payment for services should be made on the day the procedures

are carried out. I am responsible for any charges and I am aware that such payment may be made by credit card or cheque.

Patient’s Name:____________________________ Patient’s Signature:__________________________ Date:____________________

Patient Identification & Consent Form Page 2