Participant Consent Form

Selective Support will work closely with other agencies to coordinate the best support for you. This means your informed consent for the sharing of information will be sought and respected in all situations unless:

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.

I,

First Name *

Last Name *

hereby acknowledge that Selective Support has advised me of the following:

Selective Support Privacy and Confidentiality Policy and Procedure;

*

my right to access my personal information; and

my right to withdraw my consent at any time. *

I understand that the follow service(s) are recommended and relevant information about me may be forwarded to the agency(s) that provide these services, in order that I receive the best possible service:

Psychology

Occupational therapy

Assistance with daily living

Community participation

Housing

*

I understand that Selective Support must comply with relevant privacy laws and I will contact the organisation immediately if I feel that these laws have been breached.

*

My worker has discussed with me how and why certain information about me may need to be provided to other service providers *

Consent *

I understand the recommendations and I give my permission for the information to be shared with the people or agencies as detailed above.I do not give my consent for Selective Support to collect and disclose my personal information to any third parties

Name of Participant or Participant Representative *

Date *

Signature *

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