Client Consent Form

Full name (on Medicare Card) *

Medicare Number

Reference Number

Valid to

Preferred name(s)

Date of Birth *

Pronoun you would like us to use (e.g. he/him, she/her, they/them)

Mobile

Phone

Email Address *

I prefer communication by

EmailSMSletters in branded envelopes

Although unlikely, communications may be intercepted and read by people not intended for.

I understand Country & Outback Health cannot guarantee the security and confidentiality of communications.

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.

Postal address same as residential address

YesNo

Postal Address

Street address

City

State

Postcode

My Contacts

Name of Emergency Contact Person *

Client Relationship *

Emergency Contact Person Phone Number *

Consent to Share Information

YesNo

Family, significant other, carer or friend contacts

ParentCarer

Consent to share information

YesNo

Phone

Support Person

Consent to share information

YesNo

Support Person

Consent to share information

YesNo

Consent to exchange information

I permit staff from Country & Outback Health to release and exchange information to assist in my care, with my GP and the people and/or agencies listed below.

Yes

List people and/or agencies here

Consent for Support

• I consent for Country & Outback Health workers to provide support to me, which may include a range of assessments, interventions and support services.
• I understand that my contact with Country & Outback Health is voluntary, and consent is valid for 12 months while I am a current client and that 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 harm, or a crime has been committed, in which case my information including session notes could be requested or subpoenaed as part of legal processes.
• I understand that all information collected by Country & Outback Health will be treated confidentially and stored securely.

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

YesNo

Consent for information sharing

• I consent to my personal information being provided by Country SA PHN to the Department of Health and Aged Care, and in the case of mental health services to state and territory health departments/agencies, to be used for statistical and evaluation purposes designed to improve health services in Australia.
• I understand that this will include details about me such as date of birth and gender but will not include my name, address or Medicare number.
• I understand this includes the use of personal information to generate a unique key, which can be used to link my de-identified data to other de-identified data to facilitate research.
• I understand that my personal information will not be provided to the Department of Health and Aged Care or state and territory health departments/agencies if I do not give my consent.
• I also understand that my consent is not required for the Department of Health and Aged Care and state and territory health departments/agencies to include data about my use of services, combined with information about other clients, in summary, reports about the activities funded by Country SA PHN because these do not require personal information.

I understand the above information and consent to my information being shared.

Yes

Confirmation

Client Signature *

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Parent/Guardian Name (if client under 16)

Parent/Guardian Signature (if client under 16)

Draw signature|Type signatureClear

Date

**This consent form is valid for 12 months