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Consent Form

Clinical Assessment

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Confidentiality

From the moment the client gets in touch with us, everything they say is confidential.
Our confidentiality policy is held for the client's own protection, and for the protection of vulnerable adults, teenagers and children. Therefore, there will be no disclosure of the client's case or engagement.

The only limit to our confidentiality policy is when the client or others are at risk of serious harm, life threat, safety threat, or criminal activity. This limit to our confidentiality policy includes but is not exclusive to reports of child-, elder-, and dependent adult- abuse, which can be physical-, sexual- or emotional- abuse; and expressed threats of violence.

As the client's Healthcare Representative, we are mandated people, i.e. we are legally obliged to report to Tusla (National child protection, early intervention and family support services Agency) any disclosure or concern of abuse or neglect, that is physical, sexual or emotional, and that occurs to anyone who is now under 18 years of age, or who was under 18 years of age at the time of the experienced abuse if the perpetrator has access to other children. Please note that, therefore, the limit to our confidentiality policy also includes retrospective reports of abuse, for example, if the client is an adult now and they disclose having been abused as a child.


Note:

  • If you are in crisis, you can always text HELLO to 50808 or Call Samaritans using their freephone 116 123

  • Alternatively, if you have a risk emergency and need to reach us outside of hours, you may use our emergency phone contact and WhatsApp, 0899 72 42 30.

  • Please note that we are not an emergency service, such as hospitals, psychiatric units, Accident & Emergency (A&E), ambulances, police, fire brigade, or 24/7 services. Therefore, we can only help you within our scope of work availability and make relevant referrals for yourself.

Data Protection Policy

Dublin Mind Clinic collects and stores the client's personal information safely for the purpose of delivering the services provided by Dublin Mind Clinic to our client. In addition, the client's anonymous data is solely used for the purposes of research and development of our services. Dublin Mind Clinic keeps the client's data due to legal requirements for seven years from the date they last engaged with our services, after which all of their data will be destroyed to protect their confidentiality further. In the case of clients who are minors, their data will be kept until they reach 24 years of age, after which point their data will also be destroyed.
 

Engagement in Telehealth (Online only)

Telehealth is the distribution of health-related services and information via electronic information and telecommunications technologies to support long-distance clinical health care, client and professional health-related contact, care, advice, education, intervention, monitoring, remote admissions, and health administration. Telehealth technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.

Dublin Mind Clinic takes your safety and confidentiality seriously. This is why we invest on the highest standards of professional telehealth platforms, which are GDPR and HIPAA compliant, and which include encryption of all data involving your video appointment connection. In addition, none of the messages exchanged or videos used during online appointments are recorded; all video appointment data is automatically destroyed after each online session.

As much as Dublin Mind Clinic ensures your safety and confidentiality from our end, it is also crucial that you take responsibility for ensuring your safety and confidentiality from your end. Therefore, our online appointments require that you: Use a private device (not a public access device); use a private network (not a shared network); do not leave your online appointment screen open when you move away from your device; consider who may have access to your device information; ensure a private and confidential space for your online appointments; and a reliable high speed internet connection.

Sessions
A necessary Initial Clinical Psychology Consultation is included in the service of Psychological Assessments for €150.

This Consultation is led by our Clinical Psychology Experts, and it is also helpful if you are unsure whether you or your child need a full Psychological Assessment.

If further assessment is needed, this will be discussed, and the fee for this Consultation will be discounted from your full Psychological Assessment.

Psychological Assessment:


For adults this service might require:

  • 3 to 4 consultations of 1 to 1 and ½ hours duration each. These may include discussion about developmental history, diagnostic interview, screening tools, informally-based assessments, and detailed recommendations, as appropriate

  • Cognitive Assessment

  • Clinical Psychology Report, including Clinical Interpretations and Feedback regarding the client’s profile of strengths and experiences in relation to the outcome of their Psychological Assessment’s Results, and detailed Recommendations for the client and the professionals involved in their Educational and Healthcare Systems


For teenager the service might require:

  • 3 to 4 consultations of 1 to 1 and ½ hours duration each. These may include discussion about developmental history, diagnostic interview, screening tools, informally-based assessments, and detailed recommendations, as appropriate

  • Cognitive Assessment

  • It might be necessary to have a school observation of the teenager by the Clinician; however, this decision will depend on the understanding of the Clinician during the first consultation

  • Clinical Psychology Report, including Clinical Interpretations and Feedback regarding the teenager’s profile of strengths and experiences in relation to the outcome of their Psychological Assessment’s Results, and detailed Recommendations for the teenager, their family, and the professionals involved in their Educational and Healthcare System.
     


PLEASE NOTE: Since our professionals involved in this service are Psychologists and not Medical Practitioners, we will not be able to prescribe psychiatric medication for you or your teenager.

Fees

  1. Sessions must be paid in advance. You can pay your session fee via card at the reception before your session start or by paying the invoice in advance.

  2. You must first pay any outstanding session amounts before a next session can be booked.

  3. If you arrive at your session and are unable to pay any outstanding and/or current fees, it will be necessary to reschedule your session for a later date.

  4. Card payment: For card payments, please have your card ready for payment at reception before your session start. It is recommended to have a backup payment method in case the card is not accepted or if there are any technical issues.
  5. We do not accept cash or check payments.


Fees are not to be accumulated and paid at a later stage. Therefore, it is the client’s responsibility to ensure they have the required fee for their appointment.

Dublin Mind Clinic fees are competitive and take into consideration individual clients’ financial needs.

 

Late Cancellations

Late cancellations within less than 48 hours in advance of the time of your upcoming session are charged half-price.

Otherwise, a minimum of 48 hours’ notice in advance of your appointment time is required in order to cancel your session free of charge.

 

 

No Show

If no effort is made to cancel your appointment 48 hours in advance of the time of your appointment, OR if you cancel your appointment within 2 hours or less from your appointment time, you will be charged in full for your missed session.

Otherwise, a minimum of 48 hours’ notice in advance of your appointment time is required in order to cancel your session free of charge.


 

Being late

If you are late for your appointment, we will do what we can to give you your full treatment time. However, treatment time may be shortened to allow us to finish on time for the next client.

 

First Appointment

You may call or e-mail Dublin Mind Clinic to make your first appointment. Although GP referrals are appreciated, they are not a requirement and you may make an appointment directly with us.

Housekeeping (in-Person Appointment)

Electronic devices and distractions: All mobile phones and electronic devices must be switched off, or put on airplane mode in order not to disturb the clients’ sessions in the Dublin Mind Clinic.
Food and drinks: No food or drinks are allowed inside Dublin Mind Clinic therapy rooms, with the exception of a bottle of water that may be taken with you to your session.

General Notes
Please note that we do not provide any advice regarding clients’ health insurances and taxes and clients’ eligibility to claim for their fees. It is the client’s responsibility to inform themselves with their health insurance about whether they are or not eligible to claim their fees.

Please be aware that Dublin Mind Clinic cannot answer to time-sensitive queries or concerns from clients that emerge between or outside of their sessions. Therefore, we ask that such time-sensitive queries or concerns are brought to your next session, where they can be addressed and planned.

Permission to be contacted

Please let us know if you give us permission to contact you/the client between or outside of sessions where necessary or in your interest.

I hereby consent Dublin Mind Clinic to contact me via:

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How do you identify yourself?

We require filling the consent form before booking an appointment.

To commence therapeutic services, we are legally required to collect certain information seen as 'sensitive protected data' under EU (GDPR) laws. For this, we kindly ask for your consent.


This process takes only ~10 min to complete but allows the therapist to study your case and in turn offer a more time-efficient experience for you.


Please note: this form is optimised for PC/Mac browsers. If you have difficulties completing it on your phone, we kindly ask you to try a browser on your PC/Mac.

Estimated completion time: 10min

Permission to contact other professionals
As a means to supporting you with our best service delivery, Dublin Mind Clinic may occasionally need to contact your GP or Psychiatrist to liaise with them to ensure the achievement and continuity of your best outcomes.

Therefore, please let us know if you give us permission to contact your:



 

Research and Training at Dublin Mind Clinic (Optional)

At Dublin Mind Clinic, we enable staff training and development in order to maximize our team’s professional excellence. In addition, we facilitate research projects to help maximize and update our empirical work further.

For the purposes of training, it may be that you might be asked for permission for one of our staff members to observe your session. For the purposes of research, it may be that you might be asked for permission for your stored data to be studied. Please bear in mind that, all stored data is anonymized so that it cannot be linked to any client from whom the data is collected. Therefore, stored data is never identifiable and client identity is confidentially protected at all times. Furthermore, any research studies which are carried out are firstly subject to full ethical approval from a trusted Academic Research Ethics Committee.

Please note that you are under no obligation to consent to this research and training section of our consent form. Your decision to take part in this section is voluntary and it will in no way affect the services provided to you at our clinic.
If you are happy to have one of our staff members observe some of your sessions, please tick the box below (optional).

If you are happy to have one of our staff members observe some of your sessions, please tick the box below (optional).

If you are happy for your confidential and anonymized stored data to be studied for research purposes, please tick the box below (optional).

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