Alite Mind Client Informed Consent Form

"*" indicates required fields

As part of the provision of service to you, including but not limited to counselling, coaching, mindfulness therapies and classes, ALITE MIND needs to collect and record personal information from you. In accordance with relevant privacy and confidentiality legislation, the information collected may include (but may not be limited to) your name, contact details, medical history, employment status and other relevant information as appropriate.

The collection of this information is a necessary part of your participation in ALITE MIND COUNSELLING / COACHING. Your informed consent must be given prior to commencement of services.

Privacy and Confidentiality

Your personal information is gathered as part of the service you are engaging in. Information is securely stored and is retained in order to document what occurs during coaching sessions. This helps the Practitioner to provide a tailored service specific to your needs.

Limits to Confidentiality

All personal information gathered by ALITE MIND during the provision of services remains confidential except when:

1. It is subpoenaed by a court; or

2. Failure to disclose the information would, in the reasonable belief of ALITE MIND place you or another person at serious risk to life, health or safety; or

3. Your prior approval has been obtained to

a) provide a written report to another professional or agency;
b) discuss the material with another person;
c) disclose the information in another way; or

4. You would reasonably expect your personal information to be disclosed 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; or

5. Disclosure is otherwise required or authorised by law.

Consequence of Not Providing Personal Information

If you do not wish for your personal information to be collected in a way anticipated by this consent form, ALITE MIND may not be able to provide the COUNSELLING / COACHING service to you.


If client is under 18 years of age:

This field is for validation purposes and should be left unchanged.

Subscribe to our newsletter