Client Consent to Exchange Information

Consent to Exchange Information

if you have any questions about this form please contact Susan (Practice Manager) on 07 4444 4544
Your Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Your Email Address
example@example.com
Are you filling this consent form out for yourself or for someone else*

for myselffor someone else
Name of Enable OT Practitioner*

First NameLast Name

Your D.O.B. (date of birth)

DayMonthYear
Date
I {yourName4} (dob: {yourDob12}) give my treating practitioner {nameofclinician} at Enable Occupational Therapy in Mental Health, authorisation to exchange verbal and written information relevant to my case with:
the following people:

other health professionals previously and currently involvedmy NDIS Support Coordinatormy support workersother professionals (eg. Teachers, lawyers,trainers, HR personnel etc)significant others (family, friends, employers)Other
Let us know if there are specific ways we are (or are not) to share information with any of the above people:
nothing to add at this stage
I'm happy for my image (photo/video) and voice to be recorded and stored by EnableOT for the purposes of therapeutic engagement according to Australian Privacy Principles.

YesNoHappy to be asked at the time
I consent for my image to be shared with the following people/services I list here. (Add each person/service separately and let us know what they mean to you - eg. John Johnson: who is my father / or Tom Thompson: my support coordinator)

Name of person you are completing this form on behalf of

First NameLast Name
Their relationship to you
ie Child, Grandchild
Their D.O.B. (date of birth)

DayMonthYear
Date
I {yourName4} give {nameofclinician} (treating practitioner) at Enable Occupational Therapy in Mental Health, authorisation to exchange verbal and written information relevant to the care of my {theirRelationship}, {nameoffocusperson} (dob: {theirDob11}) with
the following people:

other health professionals previously and currently involvedmy NDIS Support Coordinatormy support workersother professionals (eg. Teachers, lawyers,trainers, HR personnel etc)significant others (family, friends, employers), andOther
Let us know if there are specific ways we are (or are not) to share information with any of the above people:
nothing to add at this stage
I'm happy for photo's to be taken and stored by EnableOT for the purposes of therapeutic engagement according to Australian Privacy Principles.

YesNoHappy to be asked at the time
I consent for images to be shared with the following people/services I list here. (Add each person/service separately and let us know what they mean to you - eg. John Johnson: who is my father / or Tom Thompson: my support coordinator)

I agree to have tertiary students present and involved in providing services. I understand that any student will be introduced to me in a way that makes it clear that they are students on clinical placement and not clinicians.

YesNoHappy to be asked at the time
I am aware of a current/former connection with an EnableOT Team Member and this may represent a 'conflict of interest' for me or them.

YesNo
Details of current/former connection with EnableOT Staff Member (Name of staff member; brief description of relationship; and any conditions you wish EnableOT to meet) - or request Practice Manager to contact you to discuss this further.
How often would you feel comfortable being invited to provide feedback (knowing you can volunteer to complete feedback at any time). I'm happy to be invited:

Each sessionEvery 6 monthsNeverOther
I realise that this consent can be withdrawn at any time and replaced with a different agreement by discussing this with my clinician or simply using this same link to complete a new form.

I understand that any sessions with students on their own, are provided free-of-charge and that I can decline student involvement on a singular or ongoing basis at any time by speaking with my regular clinician or the Practice Manager.

I understand that I will be asked to provide feedback on services provided by Enable Occupational Therapy and participate in audits as required by such agencies as NDIS.
Name of Signatory*
Date*

DayMonthYear
Date
Signature*

Clear
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