Informed Consent: One To One Sessions
Please complete the consent form below prior to commencing sessions. Your privacy, confidentiality, and personal data are of primary concern to practicing psychologists working on behalf of Larry Maguire and HumanPerformance.ie. Psychologists are scientist-practitioners, meaning our professional practice is grounded in a body of scientific knowledge and professional conduct. We are committed to ethical practice, which means that we are alert to the misuse of specialised knowledge and the risks to well-being of our clients. As members of the Psychological Society of Ireland (PSI), our psychologists are compelled to adhere with the provisions of the PSI Code of Professional Ethics. As such, information you wish to share before, during and after our one to one sessions will only be used for the means of intervention and will not be shared with any outside party. However, in the case where you may indicate intent to harm yourself or others, we are obliged to process and provide this information to a professional third party.

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Please indicate if you are you completing this form for yourself or on behalf of another adult. *
Client Full Name *
Please enter your full legal name or that of the person on whose behalf you are acting
Client Date of Birth *
Please enter your DOB or that of the person you are acting on behalf of
MM
/
DD
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YYYY
Client Full Address *
Please enter the address at which you, or the person you are acting on behalf of, are currently living
Client Phone Number *
Please enter your phone number or that of the person you are acting on behalf of
Client Closest Family Member *
The person closest to you that can be contacted in case of emergency
Phone Number of Closest Family Member *
I grant HumanPerformance.ie and its practitioners permission to contact me through the following methods: *
Where you are completing on behalf of another, indicate your own preferred contact method
Required

Referrals: Occasionally, and in certain situations, it may be necessary for your psychologist to contact your GP or refer you to other specialist professionals in order to assist you. Please provide your consent.

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Required

Mobile Phones and other electronic devices should be turned off or set to airplane mode throughout the session. There is no waiting area at the practice. Therefore, please attend your session at the scheduled time to avoid any inconvenience to yourself. Food should not be consumed during sessions. A bottle of water is ok so feel free to bring with you.

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Required
Privacy: Your sessions are not recorded, however, CCTV is operational on the exterior of the premises. *
Required
Expenses: We cannot provide advice regarding health insurance, work, or business expense claims. Please consult with your tax adviser, HR department, or insurance company. *
Required
Fees & Payment Terms: Fees must be settled in advance via Stripe/Revolut payments in the session booking form, by card or transfer. Sessions can be carried forward only where cancellation is received 24 hours in advance. *
Required
Consent: I confirm that I have read, understand and consent to the terms as listed above. I agree to share the details of my challenges and goals and commit to attending sessions at the pre-booked dates and times. I understand that I can terminate our arrangement at any time. 
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