Information Consent Form

Client's Name *

Date of Birth *

NDIA#

Address *

City or Suburb *

State *

Post Code *

Contact Nomination *

Contact Me

Contact my Representative

Parent/Guardian/Support Person Name/s

Phone

Mobile

Email *

CONSENT TO SERVICE

Consent to Service *

I consent to myself / my child / the person I support receiving a service from PoDDSS

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:

Educational/Vocational personnel.

Medical practitioner / specialist doctor / health professionals/QLD health

Representatives of relevant funding body e.g.: NDIS *

Suppliers of equipment/Contract Services *

Quality Audit Organisations *

Quality Improvement, Research and Development *

Advocacy – IANQ/TMSG *

Third Party Providers *

Please provide details of Third Party Providers

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

Is a Positive Behaviour Support Plan required? *

Yes

No

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 *

I/We understand and agree our consent as detailed above.

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

Teaching and Staff Education *

Lectures to Health Professionals *

Behaviour Management Purposes *

PoDDSS Marketing (including website, social media, advertising & publications) *

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 *

I have read and understood the above Consent Form. I have read and been provided a copy of the Privacy Statement which I understand and agree to the conditions.

WITNESSES

Client Age *

Under 18

18+

Client Name *

Client Nominee (Optional)

Relationship to Client

Parent or Guardian *

Witness Name *

Date *

Understanding of Consent *

I/We have read and understood the above Consent Form. I understand by Submitting this form I am agreeing to the terms and conditions detailed in the Privacy policy.

NDIS Plan Upload (optional)

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Information Consent Form