Our Forms

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

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 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:

WITNESSES

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

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 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:

WITNESSES

Participant details

Referral Details

If you ticked any of the above, please upload an Action Plan below.

Diversity

Do you identify as:

NDIS Plan Information

Key Stakeholder details

Support Coordinator: (if applicable)

Allied Health Provider:

Direct Support provider:

Community Access Provider:

Who to contact in case of an Emergency:

Client Consent

Decision maker:

(Parent, guardian, power of attorney etc.) contact details