Client Consent

"*" indicates required fields

Client Consent Form

Participant Name*
Participant Representative*

Section 1: Personal/Health Information To Be Shared

Section 2: Record Of Consent

Consent*

I consent to information relevant to the care I receive being made available as outlined below:

  • I understand that the above service(s) are recommended and relevant information about me may be forwarded to the agency(s) that provide these services.
  • I understand that the service must comply with relevant privacy laws and I will contact the organisation immediately if I feel that these laws have been breached.
  • Management has discussed with me how and why certain information about me may need to be provided to other service providers.