D2 Connect a Provider Form

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Are you an existing Determined2 customer?* This field is required.
YESNO
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Unfortunately, this service is only for Determined2 participants. Thanks
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Your Name* This field is required.
First Name
Last Name
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With your permission we can link Determined2 with your other providers making collaboration easier. For example, we can provide a brief overview of your participation including your goals, sessions activities, support plan and feedback results, and the current plan for future sessions.

In most cases this will give your chosen provider the opportunity to know more about your time with us, give recommendations on how we can best assist you and additionally share any information about the services they provide for you with Determined2.

Updates are typically provided at the end of your service cycle (up to 3 months). This may be more or less frequent if necessary.

To complete this form you will require:

The name of the provider you wish us to connect with

The providers contact number

The providers email address

Please note that this consent to share information is to the organisation a provider works for. If this individual were to leave the organisation, we will not continue to share your information with them. We may continue to share information with another individual that you are seeing within the nominated organisation.

If you continue to work with an individual at a different organisation from the one listed in the existing Connect a Provider form, a new form will be required.
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Would you like to link Determined2 to one of your service providers?* This field is required.
YESNO
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Unfortunately, this service is to link Determined2 to one of your service providers. Thanks
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Type of provider you wish to link Determined2 withIf the
General Practitioner (GP)
Physiotherapist
Occupational Therapist
Exercise Physiologist
Psychologist
Support Coordinator
Developmental Educator
Other
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Business name* This field is required.Business name of your GP or other allied health professional. If unknown please write UNKNOWN
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Name of provider you wish us to link with* This field is required.Your selected allied health professionals name
First Name
Last Name
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Email* This field is required.Email of the selected provider. If unknown please write UNKNOWN
example@example.com
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Phone number of provider * This field is required.If unknown please write UNKNOWN
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Any addition information regarding this provider?Not compulsory, if no additional information please select NEXT
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Ok
Ok
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Is there any information about your participation that you would not like us to share with this provider?* This field is required.We will only ever share information that is relevant to your participation in one of our services.
YESNO
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Please detail what you would not like us to share with this provider.
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Ok
Ok
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Once this form is submitted, we will make contact with {nameOf} to discuss your participation in our service.

We may include extra information such as any support plan reviews, session feedbacks, or session photos as part of the update to your provider.
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Privacy and Your Information

Determined2 is committed to protecting your privacy. We collect and handle personal information that you provide on this form to develop your personal plan.

Determined2 will only use your information in accordance with relevant privacy and other laws. For us to provide the best possible service, we may need to share your personal information with others, we will seek your consent to do so where required.

If you wish to contact Determined2 about the information that you provide on this form, please call 0417 932 466 or email admin@determined2.com.au

You also have the right to access your information and seek its correction under the Freedom of Information Act 1982. For information about making a Freedom of Information (FOI) application, please contact the Office of the Australian Information Commissioner on 1300 363 992.

If you have a complement or complaint about Determined2 please click here https://determined2.com.au/compliments_or_complaints/

You can also give feedback to the NDIS Commission:

They take feedback or complaints about services that you are not happy with. You can call them on: 1800 035 544

Your Information Release

I give consent for my information to be obtained / released as indicated above. I understand that this consent will remain valid until the expiry of my current service plan.

I understand that my information can be shared without my consent, provided:

It is unreasonable or impracticable to seek 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
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Today's Date* This field is required.
Date
Day
Month
Year
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If you would like to connect more than 1 provider please submit an individual 'Connect a Provider' form for each provider (for example; if you would like to connect 3 providers, fill out this form 3 times for each individual provider).
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Your Signature* This field is required.Sign here to give consent for Determined2 to share your selected information with your nominated provider
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