Connect a Provider Form

1
Are you an existing Determined2 customer?* This field is required.
YESNO
2
Unfortunately, this service is only for Determined2 participants. Thanks
3
Your Name* This field is required.
First Name
Last Name
4
With your permission we can link Determined2 with your other providers making collaboration easier. For example, they can receive a copy of your support plan, session feedback and session notes.

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
5
Would you like to link Determined2 to one of your service providers?* This field is required.
YESNO
6
Unfortunately, this service is to link Determined2 to one of your service providers. Thanks
7
Type of provider you wish to link Determined2 with
General Practitioner (GP)
Physiotherapist
Occupational therapist
Exercise physiologist
Psychologist
8
Business name* This field is required.Business name of your GP or other allied health professional
9
Name of provider you wish us to link with* This field is required.Your selected allied health professionals name
First Name
Last Name
10
Email* This field is required.Email of the selected provider
example@example.com
11
Phone number of provider * This field is required.
12
Any addition information regarding this provider?Not compulsory, if no additional information please select NEXT
Huge
Large
Normal
Small
Ok
Ok
13
Once this form is submitted, we will send a copy of your support plan to {nameOf} for their records.
Your support plan includes basic information about you and your needs within our service, this is usually information collected at your first session or Meet and Greet.

We can include extra information that will give more details about you and your sessions, you can choose to add these next.
We highly recommend choosing these extras when linking to another health service like an Occupational Therapist, Physiotherapist or Exercise Physiologist as this information will allow them to build on the work that you are doing in our service and assist them with making more detailed recommendations.
14
Would you like to share your session feedback with this provider?* This field is required.Session feedback is the feedback you or your supports provide about your sessions
YESNO
15
Would you like to share your session notes with this provider* This field is required.Session notes are the detailed notes taken by the Immersion Therapy Specialist at the end of each session, they include distance travelled, duration of activity, intensity of activity and mood before and after session.
YESNO
16
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
17
Today's Date* This field is required.
Date
Month
Day
Year
18
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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