Consent Form


As part of providing a safe service to you, SAMSN needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, and other relevant personal information as required. This collection of personal information is a necessary part of the service being provided and will be stored securely at all times. Please note that only necessary information will be collected and stored.

A detailed description of how your personal information is managed, how you can access your personal information, and how to lodge any concerns or complaints about this service or how your personal information is managed will be provided to you on request or by accessing this information on our website here.

So that SAMSN group facilitators can do their best to establish a safe space for all participants, we ask that you read and agree to this by completing the form below.

If you have any questions or are not comfortable signing the form for any reason, please discuss this with the group facilitator prior to the first session.

Provision of a telehealth service

The privacy of any form of communication online (either via the internet or telephone) is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information SAMSN uses Zoom. SAMSN has a paid account with Zoom which is compliant with the Australian standards for online security and encryption and enables you to access the platform at no charge.

To access telehealth services at SAMSN, you will need access to a quiet, private space free of disruptions, a mobile phone and/or device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers; and a reliable internet connection. If there are any concerns relating to the quality of service being provided through telehealth, please discuss with one of the group facilitators who can address this directly with SAMSN. You are also welcome to contact SAMSN directly to discuss these concerns.

Due to the remote nature of telehealth, additional steps are required to help ensure your safety and that SAMSN meet our responsibilities and duty of care.

This form provides the basis of an agreement between SAMSN and all participants in SAMSN Eight-Week Support Groups. By confirming you agree with the Consent form you are confirming:

  • I have provided accurate information to the facilitator during the telephone assessment interview.
  • I have read and understood SAMSN’s Telehealth Eight-week Support Group rules and guidelines and agree to follow them. I am aware that breaking them could lead to being asked to leave the group.
  • Confidentiality and the limits of this confidentiality have been explained and I understand how this operates in the group.
  • If the SAMSN group facilitator is concerned about my welfare during the group, or the welfare of another person who may be affected, I agree they may contact my counsellor or another health provider if I don’t have a counsellor.
  • I agree that if I ask for a referral to a counsellor, I give permission for the facilitator to share my information with that potential counsellor.
  • I agree to notify one of the facilitators in the group if I will be late to or unable to attend a group session. I understand that missing two consecutive meetings may also lead to being asked to leave the group unless alternative arrangements have been made with the facilitators.
  • I agree to raise any concerns I may have during the eight-week group program with the facilitators. I understand I can do this by either raising it in the group or outside the group by speaking with one of the facilitators.
  • I agree to the facilitators providing a brief summary of my participation in the group to SAMSN.

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