Client Consent Form - Consent for your NDIS Information

This consent form is a record of the permission you have given in relation to your information and NDIS.

This form must be completed by the Participant/Client if they have the ability to make their own decisions. If they do not have capacity, this form must be completed by the Guardian, NDIS Nominee, Formal decision maker or Informal decision maker.

This form is used to give permission (consent) for Supportability Group Pty Ltd - trading as Supportability - Support Coordination Services ABN: 70 668 877 512 to obtain and/or share information in relation to the delivery of its services with you.

Supportability - Support Coordination Services will work closely with other agencies to coordinate the best support for you. This means your informed consent for the sharing of information will be sought and respected in all situations unless:

we are obliged by law to disclose your information regardless of consent or otherwise;
it is unreasonable or impracticable to gain consent or consent has been refused; and
the disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people.

Details of Participant/Client this consent relates to:

First Name *

Surname *

Date of Birth *

NDIS Number *

Contact Phone *

Contact email *

Address *

Street address *

City *

State *

Postcode *

General Consent

Other

A 'communication circle' is a system of communication set up as an email group to notify key stakeholders of specific information, events and updates to ensure open and transparent communication with all parties. All clients are asked to consent to who they would l ike to be included in this communication circle.

Other

Giving Consent- Specific to interactions with the NDIA/NDIS

If you need or require Supportability - Support Coordination Services to make contact with the NDIA/NDIS during our work with you/the participant, you will need to provide consent for this below for both the person (staff member) and the organisation.

This part of the form will be used for the following specific consent:

1. If you would like to give consent for the NDIA to share your NDIS information with Supportability - Support Coordination Services ;

2. If you would like Supportability - Support Coordination Services (as a third party) to do things for you with the NDIA.

Below I confirm the details of the person and/or organisation that I give consent to:

I am Giving Consent to a Person

First Name *

Surname *

This person is an NDIS provider - YES

The name of the NDIS provider is - Supportability - Support Coordination Services

Phone: 07 31612471

Email: admin@rehabilityaustralia.com.au

Address: 16 Barrack Rd, Cannon Hill. QLD. 4170 | Po Box 336, Morningside. 4170.

Relationship to the Participant

Support CoordinatorAllied Health Provider - Social WorkerPositive Behavior Support Practitioner

I am Giving Consent to an Organisation

Organisation name: Supportability Group Pty Ltd – Trading as Supportability- Support Coordination Services (ABN: 70 668 877 512)

This organisation is an NDIS provider - YES

This Organisation provides NDIS services to the person named in this form - YES

Phone: 07 31612471

Email: admin@rehabilityaustralia.com.au

Address: 16 Barrack Rd, Cannon Hill. QLD. 4170 | PO Box 336, Morningside. 4170.

Organisation Key Contact Details:

Key Contact First Name	Key Contact Surname	Key Contact Position Title
Simone	Kooymans	Administration Manager
Naomi	Griffiths-Whitfield	Administration Officer

I am providing consent for the person and/or organisation named above to have the following types of consent

Consent to change my: *

personal detailscommunication preferencescorrespondence preferencesall of the above

Consent to do things on my behalf: *

submit an application formask for a plan changesubmit claims for my current plantell the NDIA about change in my circumstancesmake a complaint or give feedback to the NDIAask to review a decision made by the NDIAsubmit additional information requested by the NDIAsubmit a request for assistive technology, home modifications, or other specific supportsall of the above

Below are other things that I want the person and/or organisation to do on my behalf, or information I want to share:

I give Consent for the following duration: *

One Time OnlyFor the Duration of the Current NDIS PlanOngoing Until a Set Date

The Set date is:

Declaration

The person completing this form confirms the following:

I acknowledge that I have been provided information regarding the 'Privacy Policy' contained within the Rehability Australia Welcome Booklet (click on link to access the Welcome Booklet).

NDIS Welcome Booklet

*

I acknowledge that I am aware of my right to access my personal information. *

I understand and agree that my personal information may be collected and why, including recorded material in audio and/or visual format. *

I understand that my provider must comply with relevant privacy laws and I will contact the organisation immediately if I feel that these laws have been breached. *

I understand why certain information about me may need to be provided to other service providers in order to coordinate the best support for me. *

I confirm the following in relation to NDIS/NDIA consent (below):
*

I understand I can get further information about how the NDIA handles my personal information from the Privacy Notice or Privacy Policy on the NDIS website. I can find this information on the NDIS website.
I understand I have given the NDIA consent to give information about me to the third party or parties I have listed on this form.
I understand that the third party or parties I have given consent to will be able to access my information and/or act on my behalf.
I understand I can take away or change my consent to share information and/or my consent for a third party to act on my behalf at any time.
I confirm the information provided in this form is complete and correct.
I understand giving false or misleading information is a serious offence.
I understand this information is protected by law and the NDIA can only share it with someone else where Commonwealth law allows, or requires it, or where I give consent.
I have given my consent freely and no one has pressured me into doing so.

I confirm that my consent will continue for the duration of my time working with Supportability - Support Coordination Services, and my consent can be withdrawn at any time. *

Yes

Name of Person completing this consent form: *

Relationship to Client *

Date of Birth *

Phone Number: *

Address *

Street address *

City *

State *

Postcode *

Email Address: *

Signature *

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Date *

Version Control

V 1.1

07/09/2024

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