QPS Self-refer Program

TFD Services Employees Assistance Statement of Understanding and Consent

Please read the following information carefully. If you have any questions, please ask the counsellor
to explain this information further.

I agree to participate in a consultation with a psychologist at TFD Services. I understand this service is provided under an Employee Assistance agreement with my employer, Queensland Police Service (QPS), and is limited to 6 sessions. I also understand that under certain circumstances the number of
sessions may be extended, but there’s no guarantee of this.

QPS access to SelfRefer information

The Queensland Police Service (QPS) will at no stage seek confidential information pertaining to information discussed during SelfRefer sessions, including case notes, reasons for attending, or therapies provided.

However, limited ‘specific information’ pertaining to the SelfRefer program may be acquired by the QPS’ SelfRefer Manager in two circumstances:

1. Following an approved WorkCover claim as a result of a psychological injury within the Queensland Police Service
2. As part of regular and random auditing of SelfRefer invoices to identify and mitigate any potential fraudulent activity.

In both circumstances, the ‘specific information’ required will be restricted to the following:

1. Member’s full name
2. Member’s payroll number
3. SelfRefer Provider name
4. Number of SelfRefer provided sessions
5. Dates of SelfRefer provided sessions

In the case of fraud auditing, when possible fraudulent activity is identified, the SelfRefer Manager may contact the relevant SelfRefer Provider and/or the relevant QPS member to investigate the matter.

By signing this consent form, I acknowledge the above limitations of confidentiality and authorise the disclosure of specific information discussed above for the relevant purposes.

Confidentiality

I understand that all my personal information will be treated in confidence. The only time confidence may be broken is when a “duty of care” legally overrides the “duty of confidentiality” held by the psychologist. Specifically, confidentiality may be overridden:

• Where failure to disclose information you have given would place you or another person at serious risk of harm.
• Where the information you have given is subpoenaed (officially requested) by a Court of Law.
• Where you provide prior approval to discuss your personal information.

Recordkeeping

I understand that my personal information will be kept on file at TFD Services, in secure storage, not accessible to any personnel outside of TFD Services.

Reports

Because of the short-term, restrictive nature of Employee Assistance counselling, reports will not be prepared for workers’ compensation, legal, insurance or family court purposes. We will provide a statement of counselling attendance, if requested. We will not provide a copy of your file to any third party.

Cancellation Policy

If, for some reason you need to cancel or postpone the appointment, notification is required by close of business (3pm) the business day prior to your scheduled appointment. Failure to do so or attend an appointment will result in losing that session entitlement under the EAP.