headspace Individual Placement & Support Consent Form

headspace is dedicated to improving the wellbeing of young Australians. While providing you with vocational support services, we need to collect some of your personal information. Privacy and confidentiality of your information is important to us. We are required to report unidentifiable information about you such as age, diagnosis, vocational outcomes to the funding provider for IPS; The Department of Social Services. Your information may also be disclosed to an independent fidelity reviewer and an independent evaluator. Please take the time to read this Consent Form carefully. If you have any questions or concerns, please talk to us before signing this form.

Personal Information and Client Records

• Your personal details, referral information and vocational support notes detailing interactions with your vocational specialist are stored as individual client records. These records are electronic. These records assist us with your vocational support services, informs our service delivery and assists with meeting our funding requirements.
• Access to all client records is protected by login passwords.
• Our staff are required to follow organisational protocols to ensure your personal information remains confidential and is only used by our staff to provide vocational support.
• Your vocational specialist will want to speak with other community based services, a family member, friend or support person to assist with vocational planning. They will speak with employers and training providers, and even talk to your mental health clinician to ensure you are receiving an integrated service. For this to occur we require your written consent.
• Our staff are expected to remain professional in all dealings with young people, staff and stakeholders. They will inform you of what information we need to collect and why. They have an obligation to maintain the confidentiality of all information that comes to them during their relationship with young people of our service.

I have been explained the following:

• Information will only be passed on to others with my consent or during instances where there are legal or serious safety concerns.
• I have a right to access my client records. I will be supported to follow organisational procedures to do so. I can request that my client records be changed if I find anything is incorrect.
• The organisation collects program information and service data. This information is for monitoring, research and evaluation purposes. I understand that should information about my interactions with the organisation be used, it will be unidentifiable and my privacy will be maintained.
• If I have any issues or concerns about the vocational support services I receive, I can talk to the IPS Supervisor or service manager to help resolve these.
• My participation in the IPS Youth Program is voluntary and I can choose to leave the program at any time.
• I have rights and responsibilities in accepting vocational support services at headspace Port Augusta. I have been given and understand the information about my rights and responsibilities.


I give my consent for headspace to collect and share information to assist with my vocational support.
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.

Consent to share information

The people I nominate headspace to collect and share information with to assist in my vocational support are listed below:
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**This consent form is valid for 12 months