Client Intake Form (Paramount Care)

Consent

Please read below and provide consent for us to provide services to the participant.
We work closely with other agencies to coordinate the best support for you. This means your informed consent for the sharing of information will be sought and respected in all situations unless:
- we are obliged by law to disclose your information regardless of consent or otherwise;
- it is unreasonable or impracticable to gain 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
Please tick*

I hereby acknowledge that I am aware of my right to access my personal informationI hereby acknowledge that I am aware of my right to withdraw my consent at any time.I understand that my provider must comply with relevant privacy laws and I will contact the organisation immediately if I feel that these laws have been breached.I understand why certain information about me may need to be provided to other service providers in order to coordinate the best support for me
Do you give Paramount Care Consent to provide support and services to the participant as selected above:*

YesNo
Name of Person giving consent*
please enter your full legal name
Relationship with Participant (if consenting on behalf of participant)*
Signature*

Clear
Date & Time
Should be Empty:

Client Intake Form