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  • Information Collection and Consent Form

  • Part A: Data Collection Information

  • Information about your needs allows for your provision of services so our team can:

    • decide if we can provide a service that suits your needs
    • develop a person-centred plan
    • create a roster/schedule
    • develop an individual medication plan (if applicable)
    • share information with support staff
    • share information with other providers or people to develop a comprehensive plan

    This form lets you tell us who we can and cannot share information. If you decide to withdraw your permission after signing this form, you can update your consent by contacting management

  • Privacy Information

  • Privacy and confidentiality

  • Personal information collection, holding, use and disclosure of personal information by this Organisation is protected by the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) (Privacy Act).

    Personal information is any opinion that identifies or could identify you and includes information about your health.

  • Personal information and documents

  • The purpose of collecting personal information from you is to:

    • provide services, including planning, coordinating, funding, implementing, monitoring and reviewing our services
    • report to government or other funding bodies of how funding is used by us,
    • take photographs and videos for therapeutic and marketing purposes
    • responding to your feedback, and
    • responding to your queries.

    This Organisation will not disclose/use information about you for any secondary purpose unless:

    • You have consented to the use or disclosure; or
    • You would reasonably expect us to use or disclose the information for the secondary purpose as it is directly related to the primary purpose; or
    • The use or disclosure of the information is required or authorised by or under an Australian law or a court/tribunal order; or
    • Our Organisation reasonably believes the use or disclosure is necessary to lessen or prevent a serious threat to life, health or safety of an individual or public health and safety; or
    • Our Organisation has reason to suspect an individual may have done something unlawful or engaged in serious misconduct that relates to organisational functions or activities.
    • Our Organisation reasonably believes that the use or disclosure is reasonably necessary to assist another person in locating a person reported as missing.
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  • Acknowledgement

  • I understand that all information provided by me or about me remains confidential unless I agree to disclose it to others.
  • I understand I can change this consent at any time by contacting welcome@homealonesupportservices.com.au*
  • I am providing my consent*

  • Part B Consent

  • I give consent for Home Alone Support Services to collect and hold my personal information*

  • Specific consent

  • Allow to assist with medication*
  • Where required and requested, support the Client to access and spend their own money.*
  • Profile photos may be taken to assist with the delivery of services. These photos will not be published outside our management system and key reference documents, e.g., support plan and medication care plan. Usage will comply with Australian Privacy Principles and adhere to our Privacy and Confidentiality policies.Photographs and videos for purposes of support provision only*
  • I give consent for photographs and/or videos to be published via various forms of media eg social media, Website, promotional material, education and training*
  • I give consent for my feedback and quotes to be published via various forms of media eg social media, Website, promotional material, education and training*
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  • Audit (opt-out)We must undergo regular audits to comply with our legal requirements. Part of this audit process involves auditors contactingsome clients to discuss the services you receive and your level of satisfaction. We are seeking to confirm if you give yourconsent for the auditors to contact you and review your file and records. Your participation is not compulsory. You can opt out if you do not want to be involved

  • Part C Authorisation to Act

  • give authority for the Organisation; to collect, store, use and disclose personal and sensitive information, including health records, for the primary purpose of service provision and directly related needs under the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) whilst I/we remain a participant of this Organisation. I know that recorded material in audio and/or visual format and outline can be shared without consent if required by law.

    If my/our circumstances change, I agree to notify this Organisation as soon as practicable.
  • Date:*
     - -

  • Note: Where a client does not have the capacity to give informed consent and does not have a legal guardian who has the authority to make decisions on behalf of the participant, the participant's parent, family member or other people with a close personal relationship to the participant may sign this form. The person who signs on the participant's behalf must print their relationship next to their name.

    Please send completed forms to welcome@homealonesupportservices.com.au

  • Client Consent for Third-Party Release of Information

  • Under The Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) and The Health Information Protection Act

    The purpose of this form is to provide consent to the release of personal information to third parties as requested by the participant, who is protected and governed by the privacy provisions of The Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) and The Health Information Protection Act.
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  • Consent to release to

  • Home Alone Support Services

    17 Crinan St Hurlstone Park

    1800 427 700

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  • Personal information that the Organisation or its staff need to release to respond to the following concern or issue:
  • I understand this may include personal information within The Freedom of Information and Protection of Privacy Act and personal health information within the meaning of The Health Information Protection Act.

    I further understand that the Organisation will only release as much information as is needed to respond to my concern and subject to the restrictions and provisions of The Freedom of Information and Protection of Privacy Act 2012 (Cth) and The Health Information Protection Act.
  • Date:*
     - -

  • Consenting to the Release of Personal Information

    • To comply with privacy legislation, consent is necessary when participants ask third parties to either advocate or make inquiries on their behalf regarding various issues or services the Organisation provides.
    • In all cases, the Organisation will only release as much information as is needed to respond to the inquiry or participant's concern.
    • The Organisation will not release certain information, e.g. information about other individuals, records subject to solicitor-participant privilege, records relating to a current lawful investigation, records the release of which would affect the safety or health of anyone).
    • If a subsequent inquiry is made by the same third party unrelated to any previous participant concern, another consent form will need to be completed.
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