CDS-MNC - 'Ave a Chat Rego Form

Thank you for your interest in our 'Ave a Chat Program.

The information in this form is to ensure we can provide you with the best possible support while in the program.

Name*

First NameLast Name

Date of Birth*

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.

Gender identity:

Do you identify as Aboriginal and Torres Strait Islander?

AboriginalTorres Strait IslanderBothNeither

What country were you born in?

What is your primary language?

Do you have a disability?

NoYesPrefer not to say

Do you have a mental health diagnosis?

YesNoPrefer not to say

Please describe your mental health diagnosis or experience

Do you have any dietary requirements and/or allergies?

What do you hope to gain from the program?

CONSENT:

Saints Care is subject to privacy laws including but not limited to the Privacy and Personal Information Protection Act 1998 (PIPA). These laws require that client
information cannot be disclosed to another person without consent from the client unless there is a risk of harm.

Your information will be stored in Saints Care's secure online system with only relevant employee's having access in order to provide a service to you.

Your rights:
As a service user you have the following rights:
• To know where your information will be kept and how it will stay secure
• To know which services have access to your personal information, under what circumstances and for what reasons.
• To withdraw or restrict consent
• To access your personal information with our service. Please alert your worker or the service manager if you wish to do this
• to know how to make a complaint or provide feedback about our service (https://saintscare.org.au/complaints-feedback/)

We would encourage you to speak with your Saints Care worker if you have any further questions about your privacy. Otherwise you are welcome to contact the Information and Privacy Commission NSW on 1800 472 679.

Client Statement
By signing this consent form you understand that Saints Care Ltd will collect your personal information for the purpose of providing service to you. This information will be kept secure within the organisations secure online systems. I understand that Saints Care Ltd is bound by and complies with the Privacy and Personal Information Protection Act 1998 (PIPA).

I understand how my personal information will be used, who will access it, and for what reason. I agree for my personal information to be used and accessed in accordance to the information provided on this form and where I have or haven’t given consent.

Click here is a manual consent form was signed

yes - manually signed

Signature

'Ave a Chat - Friendship Group Program