New Client Registration Form (Self)
Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
Date
Gender
Please Select
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Land Line
Please enter a valid phone number.
Mobile
Please enter a valid phone number.
Email
example@example.com
Identity
Please Select
Aboriginal
Torres Strait Islander
Both
Neither
If you are neither, unfortunately you are not eligible for ITC services. Please do not continue with the form.
Health Care Card
Health Care Card Expiry
/
Day
/
Month
Year
Please type 01 for the DD
Medicare Card
Medicare Card Expiry
/
Day
/
Month
Year
Please type 01 for the DD
Chronic Condition
Diabetes
Cancer
Cardiovascular
Renal
Respiratory
Eye health condition associated with diabetes
Client's GP
Practice Name
When was your last Aboriginal Health Check?
/
Day
/
Month
Year
Date
Do you have a GP Management Plan with your doctor?
Please Select
Yes
No
Do you drive?
Please Select
Yes
No
Do you have access to a vehicle?
Please Select
Yes
No
Do you have a disability?
Please Select
Yes (please list)
No
Please Specify
Please specify your disability in the box above.
Are you registered with NDIS?
Please Select
Yes
No
Do you have a Carer?
Please Select
Yes
No
Carer's Name
Carer's Number
Please enter a valid phone number.
What support are you receiving from NDIS?
Which services are providing support?
E.g NDIS, My Aged Care, Enable, CAPS
Do you have a disbility?
Client Consent
I understand the ITC Program and have been provided with a fact sheet.
I understand that my participation is voluntary and that I have the right to withdraw from the Program at any time.
I understand that a range of health and community service providers may collect, use and disclose my relevant personal information as part of my care.
I understand that the personal information collected by these organisations will be maintained in a manner consistent with National Privacy Principles. It will remain confidential except when it is a legal requirement to
disclose information; or where failure to disclose information would place me or another person at risk; or when my written consent has been obtained to release the information to a third party.
I understand that statistical information (that will not identify me) will be collected and used to see how well the Program is working and help improve services for Aboriginal and Torres Strait Islander people.
Verbal Consent
Client has given verbal consent
The following people have permission to discuss my health care needs and plans within the ITC program:
My Carer listed above
Other people (List below)
List other people
Client's/Carer's Signature
Continue
Continue
Should be Empty: