Geelong headspace Registration and Consent Form

Personal details

First Name(s)*

As it appears on your Medicare card

Last Name(s)*

As it appears on your Medicare card

Preferred Name

Date of Birth*

Birth Sex*

Gender Identity

Pronouns*

If you attend school, what is the name of your school?

Address*

Suburb*

Postcode*

Home Phone*

Mobile Phone*

Please write who the number belongs to?

Email*

We will send SMS/Phone reminders of your appointments, SMS messages about test results and SMS reminders about preventative health measures such as cervical screens, Care plans, assessments, and routine tests.

I consent to receive SMS/Phone reminders*

Yes

Medicare Card Number

Ref (Number next to your name)

Expiry Date

I don’t know my Medicare card details, but I would like headspace to contact Medicare to collect these details

Yes

Do you have a health care card?

Health Care Card Number*

Expiry Date (Health Care Card)*

Do you have a pension card?

Pension Card Number*

Expiry Date (Pension Card)*

Cultural background

Are you Aboriginal or Torres Strait Islander?*

Yes, I’m Aboriginal

Yes, I’m Torres Strait Islander

Yes, I’m Both Aboriginal and Torres Strait Islander

Unsure

Prefer not to say

If you have answered yes to the above, do you consent to the Close the Gap PBS Co-payment program? Please circle your preference

Yes

Do you identify as Culturally Linguistically Diverse (CALD)

Yes

Country of birth

Please specify what language you speak

Do you require an interpreter?

Yes

Allergies

Are there any allergies or are you sensitive to any drugs or dressings?*

Yes

Smoking

Non-Smoker

Ex-Smoker

Smoker

Alcohol

Smoking

Non-Drinker

Ex-Drinker

Drinker

Secondary contacts

Next of Kin 18+years (This may be a friend or a family member) We will contact Next of Kin If we cannot get a hold of you

Name

Relationship to you

Phone*

Address*

Suburb

Postcode*

Is the emergency contact same as NOK (Next of Kin)?*

Yes

Transfer of Health Information

You may have consistently consulted with a GP at another practice. The health information held by that GP may assist us with your future healthcare needs. You may wish to have a copy of the summary of your health record transferred to headspace. Please ask the receptionist about how this can take place.

Your personal health information is kept private and secure on an electronic data base. headspace has a privacy policy in keeping with the Health Records Act 2001 under the Commonwealth Privacy Act 1988. Please notify us promptly of any changes in your contact details. Accurate contact details help us identify you and your medical records and allow us to contact you promptly about tests and results. Our privacy policy can be found on the footer of our website.

Health information will be on a database used across 2 headspace sites (locations Geelong & Corio) Please sign your consent to the above information

Signature*

Date*

Consent for reminders

headspace uses a reminder system to help maintain your health. headspace sends reminders by post, email, telephone or SMS for procedures such as vaccinations, pap smears and other health reviews.

I consent to be contacted with reminders to maintain my health.*

Yes

headspace also sends information to the Australian childhood immunisation Register and Pap Smear Register. These registers also send reminders, which will be helpful if you move services.

I consent to be contacted with reminders to maintain my health.*

Yes

Consent to share information

Please list people/services that you agree for headspace to contact for information and /or to share your information. (eg School, GP, NDIS service provider)

Name

Relationship to you

consent to share

All information

Appointment times Only

Name

Relationship to you

consent to share

All information

Appointment times Only

Consent to contact

I agree for you to contact me by*

Phone Call

SMS

Letter

Welcome Pack

All clients will receive a welcome pack upon booking an initial appointment and every 6 months thereafter. The welcome pack will be sent via SMS when they each time they update their personal details. This is to keep you up to date with any policy changes as well as a reminder of our policy. The welcome pack explains the client wellbeing survey hAPI, privacy & confidentiality and other resources while you wait to see a clinician at headspace.

Young person’s name

Signature

Date

Parent/guardian name

Signature

Date

PMHC MDS Consent Form

This Consent Form is a record of your agreement or disagreement to the three types of consent in the Consent Information Sheet.

PMHC MDS Consent Information Sheet

PMHC MDS Consent FAQs for Consumers

Before you sign this form, it is important that you check that the following have occurred:

I have been provided with a copy of an Information Sheet about my service, and have read and understood the information;

I have been offered a copy of Stride’s Privacy Policy in a form that is accessible to me;

I have been provided a copy of the Stride Consent Information Sheet, and have read and understood the information;

I have been provided an opportunity to ask questions about the service, the conditions of consent or the privacy policy and have been provided satisfactory responses to my questions (if relevant); and

I understand that participation in Stride’s services is voluntary and that I may withdraw at any time.

Please fill in the following information by ticking Yes/No to each of the three consent options below.

Name

First Last

Address

Date

Phone

Consent Conditions

Consent to Participate

Yes

I consent to the collection and use of information about me and the services I receive, as outlined in the Consent Information Sheet. This consent condition is mandatory – you must agree.

Consent to share information with other services

Yes

I consent to sharing information about me to other important healthcare staff – like my GP – to improve the care I receive. I understand that my information will not be shared if I do not consent. Please indicate YES or NO.

What sort of information can be shared?

Is there anyone you do not want to share this information with?

Consent to share anonymised data with the Department of Health and Aged Care, and state and territory health departments/agencies.

Yes

Please indicate YES or NO

Please sign to confirm consent (PMHC MDS):

Full Name (Consumer):

Signature

Date

The below section is to be completed by the administration team

headspace staff member name

Signature

Date

SMS welcome pack sent

Yes

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Young Person’s Registration and Consent Form (Geelong)