Auditory Processing Disorder (APD) Assessment & Therapy — Consent Form

Please complete the following prior to your appointment

First Name*

Last Name

Email*

Contact Number*

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Date of Birth (if under 18, parent/guardian to sign)*

Consent to Assessment/Therapy

I consent to an audiologist from Melody Hear For You conducting an auditory processing disorder (APD) assessment and/or therapy. I understand that the assessment may include a hearing test where clinically indicated. A written report will be provided after the appointment.

If less than 2 clear business days’ notice is provided, or the client does not attend the appointment, the session fee may be charged. For NDIS clients, the fee may be claimed as a Short Notice Cancellation under NDIS pricing rules.

Privacy and Sharing of Information

I understand that all records are confidential and managed in accordance with the Privacy Act. I agree that my results and report may be provided to the referring practitioner/agency recorded on this form for the purpose of my care. Results will not be shared with any other person or organisation without my written consent, unless required by law.

Online (Tele-audiology) Assessments

For quality and accuracy, online assessments may be recorded for results analysis. These recordings are stored securely and will not be shared with any third party without my written consent.

I consent to the online session being recorded for analysis purposes.

I do not consent to recording (I understand this may limit certain analysis procedures).

Rebates for Hearing Test (if performed)

If a hearing test is included, you may be able to partially claim back fees with a valid referral.

Medicare number

Referring doctor's name

Signature (client or parent/guardian)*

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Name of signatory (print)*

Date*