Participant Information Consent Form

Part A: Data and Information Collection

We collect data and information about you to assist us to:

Provide services and supports that best suit your needs, including planning, coordinating, implementing, monitoring and reviewing our services
Conduct mandatory reporting to regulatory and funding bodies
Develop a person-centred plan
Create a roster/schedule
Develop an individual medication plan (if applicable)
Respond to your feedback and continuously improve our services
Respond to your queries
Collaborate with other service providers to develop a comprehensive plan.

You have the right to tell us to whom we can and cannot share your personal information. You can change or withdraw your consent after signing this form, at any time, by contacting HappinessFirst Pty Ltd. You also have the right to not consent to us taking photographs and videos for therapeutic and marketing purposes.

Privacy Information

Personal information collection, storing, use and disclosure by HappinessFirst Pty Ltd is protected by the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) (Privacy Act) and the Privacy Act 1988 (Cth).

Personal information is any opinion that identifies or could identify you and includes information about your health. HappinessFirst Pty Ltd will only disclose relevant and/or necessary information to any external parties you have permitted us to disclose, unless required by law.

HappinessFirst Pty Ltd is required to release information about service users (without identifying you by full name or address) to regulators and funding bodies to enable statistics about disability services and their participants to be compiled. The information will be kept confidential, used for statistical purposes only, and will not be used to affect your entitlements or your access to services. As a user of NDIS services, you have the right to access your own files and to update or correct information included in the Disability Services National Minimum Data Set collection (https://www.aihw.gov.au/about-our-data/our-data-collections/disability-services-national-minimum-data-set).

HappinessFirst Pty Ltd 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
We reasonably believe the use or disclosure is necessary to lessen or prevent a serious threat to the life, health or safety of an individual or to public health and safety; or
We have reason to suspect an individual may have done something unlawful or engaged in serious misconduct that relates to organisational functions or activities; or
We reasonably believe that the use or disclosure is necessary to assist another person in locating a person reported as missing.

Participant Details

Participant’s name *

Participant advocate / authorised representative’s name (if applicable)

Relationship to participant

Preferred mode of communication (home phone, mobile, interpreter, verbal demonstration) *

Acknowledgment

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 HappinessFirst Pty Ltd *

I agreeI do not agree

I am providing my consent *

verballyin writing by completing this form

Part B: Consent

Providing Consent to Collect, Hold and Share Your Personal Information

I give consent and permission for HappinessFirst Pty Ltd to collect and hold my personal information. *

YesNo

I consent to HappinessFirst Pty Ltd disclosing my personal information to the people and/or organisations identified in the table below.

YesNo

Select the relevant boxes below for people and/or organisations that you consent for us to receive and share information with, specific to your support service needs

Consent *

YesNo

Type of Information *

PersonalNDIS

Person / Organisation Name *

Timeframe *

Profile – photos taken to assist with identifying the participant and delivery of services; SA – Service Agreement; SP – Support Planning (including support implementation, review and monitoring).

Specific Consent

I give consent for HappinessFirst Pty Ltd to assist with medication (refer to the Medication Management documentation, if yes). *

YesNo

I give consent for HappinessFirst Pty Ltd to assist me with paying my bills / doing banking / other financial administration tasks. *

YesNo

Media

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 the Australian Privacy Principles and our Privacy Policy.

Photographs and videos for purposes of support provision only. *

YesNo

I give consent for photographs and/or videos to be published via various forms of media

I give consent for my feedback and quotes to be published via various forms of media

NDIS Audit (opt-out)

We are seeking to confirm if you give your consent 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.

I consent to participate in an audit if approached by the auditor. *

YesNo

Part C: Authorisation

I give authority for HappinessFirst Pty Ltd to collect, store, use and disclose my personal and sensitive information, including health records, for the primary purpose of service provision and directly related needs whilst I/we remain a participant of HappinessFirst Pty Ltd. I know that recorded material in audio and/or visual format can be shared without consent if required by law.

If my/our circumstances change, I agree to notify HappinessFirst Pty Ltd as soon as practicable.

Authorisation

Participant’s name *

Participant advocate / authorised representative’s name (if applicable)

Relationship to participant

Signature *

Draw signature|Type signatureClear

Date *

Note: Where a participant does not have the capacity to give informed consent and does not have a legal guardian who has the authority to make decisions on their behalf, the participant’s parent, family member or other person 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.

Participant Consent for Third-Party Release of Information

The purpose of this section 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 Privacy Act 1988 (Cth).

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 we provide.
In all cases, HappinessFirst Pty Ltd will only release as much information as is needed to respond to the inquiry or participant’s concern.
HappinessFirst Pty Ltd will not release certain information (e.g. information about other individuals, records subject to solicitor–participant privilege, records relating to a current lawful investigation, or 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 will need to be completed.

Third-Party Release Details

Print name of participant *

Print mailing address of participant *

Street address *

City *

State *

Postcode *

I consent for the release of my personal information to (name, title) *

Address of person receiving information *

Street address *

City *

State *

Postcode *

Phone number of person receiving information *

I understand that HappinessFirst Pty Ltd will only release as much information as is needed to respond to my specific concern, subject to the restrictions and provisions of the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) and the Privacy Act 1988 (Cth), and in accordance with HappinessFirst Pty Ltd’s Privacy Policy.

Consent to Release

Name of person consenting to release *

Signature *

Draw signature|Type signatureClear

Date *

Save and Complete Later

This completed consent form is retained for seven (7) years.