• The Northern Centre Client Consent Form

    The Northern Centre Client Consent Form

  • Purpose of collecting information

    As part of providing a service to you, it is a requirement that we, The Northern Centre (TNC), collect and record information from you that is relevant to your current situation. Information gathering is a key requirement of the assessment and case planning process. Your information is securely and confidentially stored and enables the TNC Worker to provide a relevant and informed service.

  • I give permission for the organisation to collect and store personal information about me*
  • Do you consent to be contacted in the future for confidential feedback, research or evaluation ?

  • Confidentiality

    All personal information gathered for the provision of services remains confidential, is securely stored, and can only be released to a third party with your verbal or written permission, except in the following situations:

    • It is subpoenaed by a court of law
    • We become concerned that you are a danger to yourself
    • We become concerned that a child is at risk of harm. Failure to disclose information would place you, your child or another person at risk of harm
    • You advise us of an intended or actual crime including child abuse, assault, theft or fraud
    • There is need to warn a third party who may be in danger
  • I understand these limits to confidentiality*
  • I understand that this consent form applies to any children who are in my care and under the age of 16 years. Young people (16 years and over) who are in my care will need to sign their own consent form.*
  • I understand that my data, which will not identify me, may be released to relevant organisations for the purposes of data reporting and maintaining funding arrangements.*
  • During your support period, your Worker may recommend additional service supports to assist you in reaching your goals. I agree to my personal information being shared with and collected from other organisations who are involved in providing support to me.*
  • Photo Consent: I give consent for myself or my children being photographed and/or recorded during my participation ................................. group, for any ongoing promotion and marketing of this group.*
  • Withdrawal of Consent: I am aware that I can withdraw this consent at any time by emailing TNC on connect@tncinc.org.au.*

  • Requests for access to your information

    You may request to see information that is kept in your file in accordance with our service policy. If you are a current client, your Worker will arrange this for you. If you are a previous client, you can make a request to the Chief Executive Officer of the organisation via email: ceo@tncinc.org.au.

    Concerns/ Complaints/ Feedback

    If you have any concerns/ complaints/ feedback about the support provided to you by TNC, please click https://thenortherncentre.org.au/concern-complaints-feedback/ to find out how you can tell us about your experience.

  • The Northern Centre Client Charter of Rights & Client Code of Conduct

  • Client Charter of Rights

    • The Northern Centre will work in partnership with you to make sure you receive the best possible assistance to resolve your concerns and reach the best possible outcome.
    • We are committed to working with you in a respectful manner at all times in a way that protects your dignity, is fair and does not discriminate against you on the basis of race ethnicity, national origin, gender, sexual orientation, religion, personal values, age, disability, and economic status.
    • Your personal privacy will be respected and confidentiality protected, except where we have a legal obligation, and we will explain to you what this means when you use our service.
    • You have the right to use our service if it matches your needs and the eligibility criteria of our funding bodies.
    • You have the right to put forward a complaint and we will respond in a confidential, respectful and timely way.
    • You can expect our service to meet health and safety requirements.
    • Through our feedback process, we will ask for your opinions and seek suggestions on the service and support you received.

  • Client Code of Conduct

    • As a client of The Northern Centre you have a responsibility to:
    • Be respectful of others, including staff, volunteers and other clients
    • Be respectful of the organisation’s property
    • Be an active participant in your service
    • Follow any program guidelines set out by the organisation
    • Participate in the service in a fit state (not under the influence of drugs or alcohol)
    • Maintain confidentiality regarding information about other clients or participants in groups or programs
    • Provide accurate information about yourself in order to receive the best service

    Please note, that whilst you are actively participating in the service, we will take all reasonable steps to make contact with you. This will include all forms of contact, comprising of phone calls and/or emails and/or text messages. Should we not receive responses from you within a reasonable time frame, we may make the decision to close your file. This will not prevent you from using our services or affect your access to our services at a future date, as long as you continue to meet service eligibility.

  • Client Consent

    I agree to the statements made in this Consent Form, the Client Charter of Rights and Code of Conduct.

  • I am looking for the following support from TNC*
  • Today's Date*
     / /
  • Consented by:*

  • Parenting Program & Group Participant Details and Consent

  • I am looking for the following support from TNC*
  • Do you identify as:*
  • Format: 0000-000-000.
  • Date of Birth:*
     / /
  • Do you identify as Aboriginal or Torres Strait Islander?*
  • Do you require a translator?*
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