Participant Consent Form Please enable JavaScript in your browser to complete this form. Participant Consent Form Participant Consent Form Territory Disability Services Participant Information Name Date of Birth Gender Service Commenced File Number Notes Participant Representative Section 1: Personal / Health Information to be Shared Service TypeName of AgencyType of InformationPurpose Section 2: Record of Consent I, _____________________________ (client/carer/advocate name) consent to information relevant to the care I receive being made available as outlined above: I understand that the above service(s) are recommended and relevant information about me may be forwarded to the agency(s) that provide these services. I understand that the service must comply with relevant privacy laws, and I will contact the organization immediately if I feel that these laws have been breached. <company name> will protect and store all my information in a locked file and will not distribute my documents other than the listed services mentioned above. Management has discussed with me how and why certain information about me may need to be provided to other service providers. I understand that recommendation and I give my permission for the information to be shared with the people or agencies as detailed above. I agree for auditing bodies to access my files for review of <company name> Quality assessment. I agree for <company name> to collect recorded material in audio/visual format for myself or on my behalf. Signatures Client / Representative Signature Date Company Representative Signature Date Submit Reset Submit
