Please complete all information required in the form fields below
Please enable JavaScript in your browser to complete this form.headspace Client consent formThis form is used to gain consent for young people accessing headspace centres.Surname *First Name *Date of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920headspace siteWhyallaPort AugustaPort LincolnConsent for supportConsent for supportI understand that the service is voluntary and consent is valid for 12 months. I understand I can change or withdraw my consent at any timeI understand headspace does not provide emergency services or after hours careunderstand my details will remain confidential, unless there is a serious risk of me harming myself, harming others or if a crime has been committedI understand that my information including session notes may be requested or subpoenaed as part of legal processes.I understand that if I miss or cancel two appointments in a row with less than 24 hours notice or without a valid reason I will be closed from the serviceI consent for headspace clinicians and support workers to provide support to me which may include a range of assessments and intervention services.Please select any stream you DO NOT consent to. Service streams include:Mental healthVocationalDrug and AlcoholSexual HealthConsent to exchange informationConsent to exchange informationI 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 give permission for staff from headspace to release and exchange information to the people or agencies listed below to assist me in my care:Country & Outback Health (headspace team) & mental health services (Youth Partnership)Choice 1YesNoPlease list relevant servicesFamily member/ significant otherChoice 1YesNoFamily member/ significant otherDoctorChoice 1YesNoDoctorSchool/ workChoice 1YesNoSchool/ workJob support agencyChoice 1YesNoJob support agencyLegalChoice 1YesNoLegalOtherChoice 1YesNoOtherBut not including information regarding:Consent to Email and SMSAlthough 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:Your EmailYour Mobile Phone *ConfirmationVerbal consent receivedYesI have received and understood the headspace Rights & Responsibilities brochure and Welcome PackYesClient Signature * Clear Signature Sign here using your mouseDateDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Carer 1 Signature Clear Signature Sign here using your mouseCarer 1 NameDateDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Carer 2 Signature Clear Signature Sign here using your mouseCarer 2 NameDateDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Staff Signature Clear Signature Sign here using your mouseStaff NameDateDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920**This consent form is valid for 12 months MessageSubmit
