Privacy Consent Form (Easy Read)

What is a consent form?

Your informed consent for sharing information will be sought and respected in all situations. You can tell us how you want us to use your information.

The form records your name.

We may collect the following personal information: participant details, identifiers, service details, medical information, financial information, and interaction records. We may collect recorded material such as audio and visual formats.

Your choices

Please select yes or no to the following:

• No, I do not want you to use any information about me.
• Yes, you can use information about me for purposes authorised by me.

You can then tick each permission you agree to:

• I understand that Disability and Mental Health Care Pty Ltd will collect, store and use the information collected to provide services to me.
• I give permission for photos to be published on Disability and Mental Health Care Pty Ltd's website or social media.
• I give permission for use of my data for internal training and operational purposes.
• I give permission to participate in NDIS audits and other activities.
• I consent to my information being provided to other service providers.
• I consent to my information being provided to authorities such as health professionals, medical specialists and so on — specifying who your information can be provided to.

If you want to change your consent to any of the above, you can tell us.

Signing

You sign your name with the date. You can get someone to sign the form for you — the form records the representative's name and signature.

What happens with this form?

We will keep this form private and in a safe place.