headspace client consent form

Please complete all information required in the form fields below

headspace client consent form

If you need assistance with this form from your parent/guardian please ensure they are with you to complete and submit
If you have any questions about this consent form please discuss with your worker during your appointment

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.

Your Pronouns (he/him/she/her/they/them)

Name of Emergency contact person

Emergency Contact Phone

Consent to share information with Emergency Contact

Name of Carer

Carer Phone

Consent to share information with Carer

Consent for Support

• I consent for headspace 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 headspace. I understand I can change or withdraw my consent at any time.
• I understand headspace 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 headspace 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 by headspace to Country SA Primary Health Network to the Department of Health to be used for statistical and evaluation purposes designed to improve health services in Australia. I understand this will include details about me such as my date of birth, gender and types of services I use but will not include my name, address or Medicare Number. I understand that my information will not beprovided to the Department of Health if I do not give my consent.

I permit staff from headspace to release and exchange information to assist in my care with my GP and the people and/or agencies listed below (Please specify any limitations to exchanging information)

Consent to Email and SMS

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

Your Email

Your Mobile Phone

Confirmation

I have received and understood the headspace Rights & Responsibilities brochure and Welcome Pack
Yes

Client Signature *
Sign here using your mouse

Parent/Guardian Signature (if client under 16)
Sign here using your mouse

Parent/Guardian Name (if client under 16)

Date *

**This consent form is valid for 12 months

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