Participant Consent Form

Provider Declaration

The provider will work closely with other agencies to coordinate the best support for you. We need your consent to share your information, except when:

● we are obliged by law to disclose your information regardless of consent or otherwise.
● it is unreasonable or impracticable to gain consent or consent has been refused; and
● the disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people.

Participant Details

Participant Consent

I give consent to:
● collect the information, including audio and visual records, needed to provide me services.
● store information about me.
● allow staff, who need my information to provide services to me, access to information about me.
● share my information except with the people and/or organisations listed below.

Parties Excluded from Information Sharing

Information must not be shared with the following people or organisations:

Signature

Verbal Consent: Staff use only

Verbal consent should only be used where it is not practicable to obtain written consent.
I have discussed the proposed referrals with the participant or authorised representative and I am satisfied that they understand the proposed uses and disclosures and have provided their informed consent to these.