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Personal Details
Full Name
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DOB
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Mobile
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Home Phone
Email
Gender Identity
[Gender Identity]
Female
Male
Non-binary
Transgender
Intersex
I identify as another gender
I prefer not to say
Current Address
Suburb
Postcode
Country of birth
Language spoken at home
Identify as
Aboriginal
Torres Strait Islander
Culturally and Linguistically Diverse
LGBTIQA+
Formal Supports
NDIS
GP
Psychiatrist
Psychologist
Counsellor
Community Mental Health
Other Support Program
Marital Status
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Defacto
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Regularity of Contact
Convenient Day/s
Monday
Tuesday
Wednesday
Thursday
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Time of Day
Morning (10am-1pm)
Afternoon (1pm-4pm)
Anytime
Frequency
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Preference of Caller
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Emergency Contact
Name
Home Phone
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Email
Relationship to you
Referrer Contact (if applicable)
Name
Mobile
Home Phone
Email
Relationship to you
Conditions
Primary Diagnosis (if known)
Other Illnesses (mental/physical)
Interests
Other Notes
Consent to collection and use of personal information
I understand that One Door Mental Health (One Door) needs to collect my personal information to provide services to me. This information may be shared between programs within One Door and/or with approved sub-contractors and partners who are providing services alongside One Door
I agree to my de-identified personal information being used for research, evaluation and auditing purposes by One Door
I agree to my deidentified information collected by One Door being disclosed to funding bodies where this is required by funding agreements or law (eg: Federal Department of Health, NSW Health)
I agree to my deidentified information being disclosed to State or Territory authorities (optional)
I understand my personal information will only be recorded and disclosed in accordance with the
Privacy Act 1988
and the
Australian Privacy Principles 2013
.
Under the Privacy Act there are some situations where your information may need to be given without your consent. For example, if:
there are significant concerns regarding yours or others health or safety
One Door receives a court order to provide client records.
I can request to see the information collected about me.
If I have questions about my consent and privacy, I can call
1800 843 539
(THE KEY) or email
information@onedoor.org.au
to ask questions..
Read our
Consent Information here
.
I have read the above and the Consent Information document and understand the information it contains.
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- required
Yes
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