Client Consent Form

All new clients are required to complete this consent form and agree to the Terms and Conditions of our service at the end of the form. If you feel unsure, confused, or do not agree with any part, please do not complete the form. Jessica will not be able to provide services in this case. We encourage you to take your time to fully understand what you are agreeing to — there is no rush or pressure to book your assessment.

First Name *

Last Name *

Mobile Phone

Date of Birth

Email Address

Address

City

State

Postcode

Emergency contact name

Emergency contact number

We use NovoNote, an AI-assisted tool that helps clinicians take notes so we can focus on listening and supporting you during sessions.

NovoNote creates a summary of your session, which is saved in your file. The full transcript is usually deleted, and audio is never stored.

NovoNote meets Australian Privacy Principles, AHPRA, and HIPAA standards, runs on a secure server in Australia, and your data is not used to train AI models.

For more information on security, visit: NovoPsych NovoNote Security

I agree to receive services via telepractice. *

I understand what this assessment involves and have had the chance to ask questions. *

I agree to my session audio being used by NovoNote to create a session summary *

I understand that to book my appointment, I must pay a 50% deposit. This deposit is non-refundable if I cancel within 48 hours or do not attend. The remaining 50% will be charged on the day of my appointment. * *

I understand that Jessica is a psychologist and does not prescribe medication *

I understand that I may not meet the criteria for autism or ADHD. *

I understand that Jessica’s assessments and diagnoses are final. *

I understand that the assessment does not guarantee medication or approval for NDIS, government, or other programs *

I understand that my report may take up to six weeks. If it takes longer or I need it sooner, I can follow up once via email. * *

I have read and agree to the Terms and Conditions of Service. * *

Signature *

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Name *

Date *