Information Consent Form

Confidentiality and Privacy

Prior to commencement of services, we require all participants to complete an Information Consent form.

Completing an Information Consent form is crucial in enabling PoDDSS to engage with your support network to assist in the development of your individualised support file.

Complete online

CONSENT to Obtain or Release INFORMATION FORM - CLIENT SERVICES

Contact Nomination *

CONSENT TO SERVICE

Consent to Service *

AUTHORITY DISCLOSE AND COLLECT INFORMATION

To ensure quality of service provision and, in some instances, obtain government funding, PoDDSS may need to share relevant information about you / your child with other agencies. For further information about the confidentiality of your personal information please refer to the PoDDSS Privacy Policy.

I/We authorise officers of PoDDSS to release or obtain information to/ from:

CONSENT FOR DEVELOPMENT OF A POSITIVE BEHAVIOUR SUPPORT PLAN FOR THE PERSON

Is a Positive Behaviour Support Plan required? *

I/We give my permission for the PoDDSS Behaviour Support to obtain or share information about me with the people and organisations I have indicated above.

I understand that the purpose of obtaining and releasing my information is to help the PoDDSS Behaviour Support to provide services to me, and it has been explained to me that information will only be shared for this purpose.

I understand that the PoDDSS Behaviour Support needs to share information about me with the government departments or services I receive, services that this can occur with are listed above.

Consent to create a Positive Behaviour Support Plan *

CONSENT TO VIDEO, PHOTOGRAPHY AND MEDIA

I/We hereby give permission for photographs/video footage of the above named to be used by PoDDSS for the following purposes

I/We UNDERSTAND THAT:

  • Any photographs, video footage and other images taken by PoDDSS may be shown in a public environment
  • Photos or videos will not be given or sold to third parties
  • PoDDSS may keep and use photographs and video footage unless otherwise notified in writing
  • There is no payment for appearances in any photo or film used by PoDDSS
  • PoDDSS staff will always have the client and their family’s best interest in mind when using the photographs, video footage and other images for the purposes listed above
Understanding of the above information *

WITNESSES

Client Age *
Understanding of Consent *
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