{"id":23705,"date":"2025-05-07T13:29:48","date_gmt":"2025-05-07T13:29:48","guid":{"rendered":"https:\/\/versionx.bronwynrusso.com\/?page_id=23705"},"modified":"2025-05-07T13:32:08","modified_gmt":"2025-05-07T13:32:08","slug":"minor-in-person-consent-forms-privacy-statements","status":"publish","type":"page","link":"https:\/\/versionx.bronwynrusso.com\/?page_id=23705","title":{"rendered":"(Minor) In-Person Consent Forms &#038; Privacy Statements"},"content":{"rendered":"<section data-bb-version=\"5.2.4\" id=\"bt_bb_section69d2c49d7bac9\" class=\"bt_bb_section bt_bb_layout_boxed_1200\"  data-bt-override-class=\"null\"><div class=\"bt_bb_port\"><div class=\"bt_bb_cell\"><div class=\"bt_bb_cell_inner\"><div class=\"bt_bb_row \"  data-bt-override-class=\"{}\"><div class=\"bt_bb_row_holder\" ><div data-bb-version=\"5.2.4\"  class=\"bt_bb_column col-xxl-12 col-xl-12 col-xs-12 col-sm-12 col-md-12 col-lg-12 bt_bb_vertical_align_top bt_bb_align_left bt_bb_padding_normal\" style=\"; --column-width:12;\" data-width=\"12\" data-bt-override-class=\"{}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_column_content_inner\"><div class=\"bt_bb_shortcode\"><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-23690\"><form id=\"wpforms-form-23690\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"23690\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F23705\" data-token=\"ec32de227e0392d1d66348fc8fad45c9\" data-token-time=\"1775420573\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-23690-field_24-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"24\"><div id=\"wpforms-23690-field_24\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-23690-field_24-error\"><p>As part of providing a psychological service to your child, I (Bronwyn Russo - Clinical Psychologist) will need to collect and record personal information that is relevant to your child\u2019s current situation. This information will be a necessary part of the psychological assessment that is conducted. Information is required to be accurate, complete and as up to date as possible.<\/p>\n<p><strong>Access<\/strong><\/p>\n<p>You may access the material recorded in your child\u2019s file upon request. Copies of reports are available although charges apply.<\/p>\n<p><strong>Confidentiality<\/strong><\/p>\n<p>All personal information gathered during the provision of psychological service will remain confidential and secure except when:<\/p>\n<ol>\n<li>It is subpoenaed by a court; or<\/li>\n<li>Failure to disclose the information would place your child or another person at risk; or<\/li>\n<li>Your prior approval has been obtained to:<\/li>\n<li>provide a written report to another professional or agency e.g. a GP or another professional; or<\/li>\n<li>discuss the material with another person e.g. a parent<\/li>\n<\/ol>\n<p>Generally files are kept for a minimum of five years then destroyed.<\/p>\n<p><strong>Cancellation<\/strong><\/p>\n<p>If you need to cancel or postpone the appointment, please give at least <strong>24 hours <\/strong>notice, otherwise you will be charged in full for the missed session.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-23690-field_1-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"1\"><div id=\"wpforms-23690-field_1\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-23690-field_1-error\"><h4>Definition of Services:<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-23690-field_2-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"2\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-23690-field_3-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"3\"><div id=\"wpforms-23690-field_3\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-23690-field_3-error\"><p>I , (Print Name In Block Capitals)<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-23690-field_5-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-23690-field_5\">Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-23690-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-23690-field_5-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-23690-field_6-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-23690-field_6\">Surname: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-23690-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-23690-field_6-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-23690-field_19-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"19\"><div id=\"wpforms-23690-field_19\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-23690-field_19-error\"><p>have read and understood the above Consent Form.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-23690-field_20-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"20\"><div id=\"wpforms-23690-field_20\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-23690-field_20-error\"><p>I agree to these conditions for the psychological service and I give consent for my child,<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-23690-field_25-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"25\"><div id=\"wpforms-23690-field_25\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-23690-field_25-error\"><p>(Print Name In Block Capitals)<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-23690-field_22-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-23690-field_22\">Name (Child&#039;s Name): <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-23690-field_22\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-23690-field_22-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-23690-field_26-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-23690-field_26\">Surname (Child&#039;s Surname):  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-23690-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-23690-field_26-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-23690-field_7-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"7\"><div id=\"wpforms-23690-field_7\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-23690-field_7-error\"><p>to be seen by Clinical Psychologist, Bronwyn Russo.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-23690-field_10-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"10\"><\/div><div id=\"wpforms-23690-field_16-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"16\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-23690-field_17-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">Client&#039;s Signature: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-23690-field_17\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-23690-field_17_1\" name=\"wpforms[fields][17][]\" value=\"I Agree\" aria-errormessage=\"wpforms-23690-field_17_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-23690-field_17_1\">I Agree<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-23690-field_17_2\" name=\"wpforms[fields][17][]\" value=\"I Do Not Agree\" aria-errormessage=\"wpforms-23690-field_17_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-23690-field_17_2\">I Do Not Agree<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-23690-field_18-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Date \/ Time: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][18][date][m]\" id=\"wpforms-23690-field_18-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][18][date][d]\" id=\"wpforms-23690-field_18-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][18][date][y]\" id=\"wpforms-23690-field_18-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><\/div><\/div><\/div><div id=\"wpforms-23690-field_9-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"9\"><div id=\"wpforms-23690-field_9\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-23690-field_9-error\"><p><strong><em>Please Note: If, after reading this page you are unsure of what is written, please feel free to discuss it with me.<\/em><\/strong><\/p>\n<p>&nbsp;<\/p>\n<p>Bronwyn Russo<\/p>\n<p>Clinical Psychologist<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"23690\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/versionx.bronwynrusso.com\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F23705\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-23690\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/versionx.bronwynrusso.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div><\/div><\/div><\/div><\/div><\/div><\/div><!-- cell_inner --><\/div><!-- cell --><\/div><!-- port --><\/section>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":23278,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-23705","page","type-page","status-publish","has-post-thumbnail","hentry"],"_links":{"self":[{"href":"https:\/\/versionx.bronwynrusso.com\/index.php?rest_route=\/wp\/v2\/pages\/23705"}],"collection":[{"href":"https:\/\/versionx.bronwynrusso.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/versionx.bronwynrusso.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/versionx.bronwynrusso.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/versionx.bronwynrusso.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=23705"}],"version-history":[{"count":1,"href":"https:\/\/versionx.bronwynrusso.com\/index.php?rest_route=\/wp\/v2\/pages\/23705\/revisions"}],"predecessor-version":[{"id":23706,"href":"https:\/\/versionx.bronwynrusso.com\/index.php?rest_route=\/wp\/v2\/pages\/23705\/revisions\/23706"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/versionx.bronwynrusso.com\/index.php?rest_route=\/wp\/v2\/media\/23278"}],"wp:attachment":[{"href":"https:\/\/versionx.bronwynrusso.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=23705"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}