My Steps Client Consent Form - Country & Outback Health

Country & Outback Health
My Steps Client Consent Form

Please complete all information required in the form fields below

Alcohol & Other Drugs Client Consent Form

Client Details

Full name on Medicare Card *

Preferred name

Date of Birth *

Residential Address *
Address Line 1
City
State / Province / Region
Postal Code
This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.

Emergency Contact Details

Name of Emergency Contact Person

Emergency Contact Person Phone Number

Consent to Share Information

Pronoun your emergency contact uses for you (e.g. he/him, she/her, them/them)

Carer Details

Name of Carer

Carer Phone Number

Consent to Share Information

Consent for Support

Consent for Support
I consent for Country & Outback Health clinicians and support workers to provide support to me, which may include a range of assessments, interventions and support services.
I understand that the service is voluntary and consent is valid while I am a current client with Country & Outback Health. I understand I can change or withdraw my consent at any time.
I understand Country & Outback Health does not provide emergency services or after hours care.
I understand my details will remain confidential, unless there is a serious risk of me harming myself, harming others or if a crime has been committed.
I understand that all information collected by Country & Outback Health will be treated in a confidential manner and stored securely.

Consent to Exchange Information

Consent to Exchange Information
I consent to my information being provided to Country SA Primary Health Network or to the Department of Health to be used for statistical and evaluation purposes designed to improve health services in Australia.
I give permission for staff from Country & Outback Health to release and exchange information to the agencies listed below to assist me in my recovery:

Please specify any limitations to exchanging information

Yes No

GP Services
YesGP Services Yes
NoGP Services No
Family Members
YesFamily Members Yes
NoFamily Members No
Mental Health Services
YesMental Health Services Yes
NoMental Health Services No
Red Cross
YesRed Cross Yes
NoRed Cross No
Correctional Services
YesCorrectional Services Yes
NoCorrectional Services No
Housing SA
YesHousing SA Yes
NoHousing SA No
Centrelink
YesCentrelink Yes
NoCentrelink No
SAPOL
YesSAPOL Yes
NoSAPOL No
Centacare SA
YesCentacare SA Yes
NoCentacare SA No
Anglicare SA
YesAnglicare SA Yes
NoAnglicare SA No
Uniting Communities
YesUniting Communities Yes
NoUniting Communities No
Uniting Country SA
YesUniting Country SA Yes
NoUniting Country SA No
Lutheran Community Care
YesLutheran Community Care Yes
NoLutheran Community Care No
National Disability Insurance Agency
YesNational Disability Insurance Agency Yes
NoNational Disability Insurance Agency No

	Yes	No
GP Services	YesGP Services Yes	NoGP Services No
Family Members	YesFamily Members Yes	NoFamily Members No
Mental Health Services	YesMental Health Services Yes	NoMental Health Services No
Red Cross	YesRed Cross Yes	NoRed Cross No
Correctional Services	YesCorrectional Services Yes	NoCorrectional Services No
Housing SA	YesHousing SA Yes	NoHousing SA No
Centrelink	YesCentrelink Yes	NoCentrelink No
SAPOL	YesSAPOL Yes	NoSAPOL No
Centacare SA	YesCentacare SA Yes	NoCentacare SA No
Anglicare SA	YesAnglicare SA Yes	NoAnglicare SA No
Uniting Communities	YesUniting Communities Yes	NoUniting Communities No
Uniting Country SA	YesUniting Country SA Yes	NoUniting Country SA No
Lutheran Community Care	YesLutheran Community Care Yes	NoLutheran Community Care No
National Disability Insurance Agency	YesNational Disability Insurance Agency Yes	NoNational Disability Insurance Agency No

Other Services/Agencies (please list)

Although unlikely, SMS and email may be intercepted and read by people it is not intended for
I understand Country & Outback Health cannot guarantee the security and confidentiality of SMS and Email and I consent to communication via:
SMS
Email

I have received the Country & Outback Health Client Information Brochure (including rights and responsibilities).
Yes

Client Signature

Date
**This consent form is valid for 12 months

Email

Country & Outback Health My Steps Client Consent Form