Allied Referral – Care Mode

Consent

Care Mode Pty Ltd needs to collect information about the participant for the primary purpose of providing a quality service to the participant. In order to thoroughly assess, diagnose, and provide therapy, we need to collect some personal information about the participant.

With this information provided; we may be unable to support the participant. This information will also be used:

1. To ensure the process of quality treatment provision, information about the participants assessment results and progress may be given to other relevant service providers or other professionals within the team, who are involved in the participants management; and

2. Disclosure of information to the participants doctors, other health professionals or the teachers to facilitate communication and best possible care for the participant.

Care Mode Pty Ltd has a privacy policy that is available on request. The policy provides guidelines on the collection, use, disclosure, and security of the participant’s information. The privacy policy contains information on how you may request access to, and correction of, the participants personal information and how you may complain about a breach of the participant’s privacy and how we will deal with such a complaint.

Please list the names and contact details of the individuals involved in the participants care. By providing the following details you are consenting to relevant information being shared between services.

E.g., GP/Specialist

Care Mode does NOT have consent to talk to anyone? Please specify.

Consent to Record

Care Mode Pty Ltd to make voice and video recording of the participant to be used solely for the purpose of analysis and individual therapy planning or to provide supporting evidence for disability related support needs to be relevant to the funding body.

Consent to Physical Guidance

Physical guidance contact between the participant and their treating therapist as necessary. I acknowledge that all care is taken whilst working with the participant however physical contact may be required for guidance during therapy sessions, and that such contact will only be used to ensure hand-over-hand prompting, guiding the participant into a seated position etc.

Declaration of Consent

I, the participant, or nominated stakeholder, have read the above information, and understand the reasons for collecting the information and the ways in which the information may be used. I understand that it is my choice as to what information I provide, and that withholding or falsifying information might act against the best interests of the participant’s assessment and therapy progress. I am aware that I can access personal and treatment information on request and if necessary. I understand that the practice must obtain additional consent if the information collected is to be used in any ways other than outlined above.

Full Name

Select a Date

Your Signature

Consent

I have consented on behalf of the participant and have the authority to act on their behalf.

Form has been submitted successfully.

An error occured.

Refer a participant

Allied Health Referral Form

Participant Details

Diagnosis & Service

Next of Kin/Emergency Contact

Referrer Details

Plan Details

Plan Manager Details (If applicable)

Consent

Consent to Record

Consent to Physical Guidance

Declaration of Consent

Contact us

Subscribe to our e-newsletter