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Sea Change logo | Sea Change Weight Loss Clinic

Sea Change Weight Loss Clinic

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Psychology Appointment Questionnaire & Consent

  • Your Details

  • DD slash MM slash YYYY

  • Bariatric Surgery Psychology Questionnaire

    This includes anorexia, bulimia, binge eating disorder or any other eating disorder.
    This includes depression, anxiety, OCD, post-traumatic stress disorder, bipolar, personality disorder, autism, psychosis/schizophrenia.
  • e.g. diagnosis and treatment received (medication, talking therapy, inpatient admission)
    This includes cutting, overdoses, burning etc
    1 glass of wine = 2 units, 1 pint of beer = 3 units, 1 shot of spirits = 1.5 units
  • e.g. genetics, large portions, comfort-eating, health etc

  • DASS21 Questionnaire

  • Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.
    The rating scale is as follows:
    0 = Did not apply to me at all
    1 = Applied to me to some degree, or some of the time
    2 = Applied to me to a considerable degree, or a good part of time
    3 = Applied to me very much, or most of the time
    e.g. sense of heart rate increase, heart missing a beat

  • Confidentiality

  • Psychological service

    As part of providing a psychological service to you, Sea Change 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 as part of providing psychological services to you.

    This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted.

    Purpose of collecting and holding information

    Your personal information gathered as part of your assessment and treatment is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service to you. Feedback relevant to your bariatric surgery will be provided to your other treating health professionals within the Sea Change clinic, as well as your external referring party (e.g. GP or psychiatrist).

    A more detailed description is provided in the practice’s “Privacy policy for management of personal information”, which can be obtained by contacting the Sea Change administration team. The Privacy Policy contains information about how to access and seek correction of your personal information, and how to lodge a complaint about our management of your personal information.

    Disclosure of personal information

    All personal information gathered by the psychologist during the provision of the psychological service will remain confidential except when:
    1. it is subpoenaed by a court, or disclosure is otherwise required or authorised by law;
    2. failure to disclose the information would in the reasonable belief of Sea Change Clinic place you or another person at serious risk to life, health or safety;
    3. your prior approval has been obtained to:
    (a) provide a written report to another professional or agency. e.g. a GP or a lawyer; or
    (b) discuss the material with another person, e.g. a parent, employer, health provider or third party funder;
    (c) disclose the information in another way; or
    (d) disclose the information 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.

  • Fees and Cancellation Policy

  • Fees

    The cost of the initial consultation (usually around 90 minutes) is $240, which is payable at the end of the session by cash or card. The cost of subsequent sessions (usually around 50 minutes) is $160 per session, which is payable at the end of each session.

    Cancellation Policy

    If for any reason you need to cancel or postpone your appointment, you must give the psychologist at least 48 hours' notice by contacting Sea Change Clinic on (02) 4037 5858. If you fail to give such notice, you will be liable for a $50 cancellation fee, which Sea Change may deduct from your $50 deposit.

  • Emergency Care

  • Please note that the Sea Change psychology services are strictly by appointment only. We do not have the capacity to provide crisis mental health care. Should you require urgent mental health support outside of your appointment times, please contact your GP or the NSW Mental Health Access Line on 1800 011 511.

    In an emergency situation call 000.

    If someone has attempted, or is at immediate risk of attempting to harm themselves or someone else, call triple zero (000) immediately.

  • Submit

    Please note: If, after reading this form you are at all unclear about any of the information provided, please contact the psychologist prior to your appointment.
Address:
Level 2, 199 Corlette St
The Junction NSW 2291
Contact:
+61 2 4037 5858
+61 2 4047 2147
E: [email protected]
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