My Mirror (Mirror Pty Ltd)

Consent Form: Persons under 16 years old

I hereby consent to the child or adolescent named below receiving services through the My Mirror Platform. These services are provided in accordance with the My Mirror Pty Ltd Terms of Service.

Parent/Legal Guardian

Parent/Legal Guardian Full Name (as appears on Medicare card) *

Parent/Legal Guardian Contact Number *

Email Address *

Parent/Legal Guardian Medicare Card and Reference Number *

Parent/Legal Guardian Date of Birth *

Signature *

Draw signature|Type signatureClear

Date of Signature *

Patient Details

Patient Full Name *

Date of Birth *

Is the Child or Adolescent Subject to an Active Court Order? *

YesNo

Preferred Availability for Patient

Additional Details

Next Steps

You will need to create an account on our platform for your child. Remember that the details you insert when creating the account should be the child’s details (i.e. DOB and Medicare card reference), not yours. Each individual using the platform must have their own account for legal purposes. Each account must be linked to a mobile phone number. All booking confirmations will be sent to the registered mobile and email address. You can use your mobile phone number but if you intend on using the platform as well with your own account you will need to use a different mobile phone number for your child’s account. The platform will only allow a phone number to be registered once so cannot be used for two accounts. Follow this link to sign up: https://www.mymirror.com.au/signup

IMPORTANT: We kindly request that you attend the first session with your child so that you can meet with the consulting psychologist.