Alcohol & Other Drugs Client Consent

Alcohol & Other Drugs Client Consent Form

Full name on Medicare Card *

Preferred name

Date of Birth *

Residential Address *

Street address *

City *

State *

Postcode *

This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.

Post address is different to residential address

Postal Address

Street address

City

State

Postcode

Emergency Contact Details

Name of Emergency Contact Person

Emergency Contact Person Phone Number

Consent to Share Information

YesNo

Pronoun your emergency contact uses for you (e.g. he/him, she/her, them/them)

Carer Details

Name of Carer

Carer Phone Number

Consent to Share Information

YesNo

Consent for Support

I consent for Country & Outback Health clinicians and support workers to provide support to me, which may include a range of assessments, interventions and support services.I understand that the service is voluntary and consent is valid while I am a current client with Country & Outback Health. I understand I can change or withdraw my consent at any time.I understand Country & Outback Health does not provide emergency services or after hours care.I understand my details will remain confidential, unless there is a serious risk of me harming myself, harming others or if a crime has been committed.I understand that all information collected by Country & Outback Health will be treated in a confidential manner and stored securely.

Consent to Exchange Information

I consent to my information being provided to Country SA Primary Health Network or to the Department of Health to be used for statistical and evaluation purposes designed to improve health services in Australia.I give permission for staff from Country & Outback Health to release and exchange information to the agencies listed below to assist me in my recovery

Other Services/Agencies (please list)

Although unlikely, SMS and email may be intercepted and read by people it is not intended for

I understand Country & Outback Health cannot guarantee the security and confidentiality of SMS and Email and I consent to communication via:SMSEmail

I have received the Country & Outback Health Client Information Brochure (including rights and responsibilities).

YesNo

Client Signature

Draw signature|Type signatureClear

Date

**This consent form is valid for 12 months