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Referral Forms

Please note:

to complete the referral process, all three forms: Referrer Details, Client Consent, and Media Consent must be submitted.

REFERRER DETAILS FORM

Does the referrer wish to be part of the intake process?
Yes
No
Is there anyone else who needs to be included in the intake process?

SUPPORT TYPE/S REQUESTED

Support Type/s Requested

CLIENT DETAILS

Plan Management
First Nation Person
Yes
No
Prefer Not To Say
CALD Background:
Yes
No
Prefer Not To Say
Interpreters Required
Yes
No
On Youth Justice Orders
Yes
No
Guardianship Order
Yes
No
Administration Order
Yes
No

CURRENT SERVICES AND SUPPORTS

Informal Supports

Mainstream Supports

Community Supports

RISK ASSESSMENT

Has this client been known to be aggressive or violent?
Yes
No
Is there anyone at the client's property known to have been aggressive or violent?
Yes
No
Are there any risks related to pets or animals at the client's property?
Yes
No
Are there any other factors to be aware of when visiting the client at their home?
Yes
No
Are there other identified risks and/or historical factors that we should be aware of?
Yes
No
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CLIENT CONSENT FORM

This consent allows ACCER Care to exchange information with other personnel or agencies involved with your care. This will allow us to obtain relevant records to provide you with thorough, complete care and/or share them with other providers for the purposes of care coordination. De-identified data may also be used for reporting and auditing purposes.

ACCER Care may also be required, by law, to disclose your information. Please note that, once disclosed, the law does not always require the recipient of your information to maintain the confidentiality of your information.

Date of Birth
Day
Month
Year

I understand that I have the following rights:

a) To receive a copy of this signed authorisation.

b) To refuse to sign this authorisation.

c) To revoke this authorisation at any time.


I confirm that I have only given ACCER Care my consent to release, obtain, or exchange information with the following person/s, agency/ies, government department/s, and organisation/s.

Multi choice

I acknowledge that:

  • The information that can be disclosed/obtained about me may include psychological and social work counselling/treatment progress notes, verbal disclosure of information, evaluation reports, demographic information, medical results, and treatment and rehabilitation information.

  • I have read and agree to all the conditions specified in this consent form.

  • I can revoke this authorisation at any time, and that it must be done in writing and signed by me.

  • This authorisation is valid for 5 years from the date on which it is signed unless revoked by me.

  • I understand that all ACCER Care staff are Mandatory Reporters and if information is given that harm has been received to a person, or will be given to a person, they are required by law to report it to the appropriate authorities.


Do you give your consent for the exchange of information?
Yes
No
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Date
Day
Month
Year

Media & Photo Consent Form

This consent form authorises ACCER Care to utilise and share photographs, videos, and images for promotional purposes, which may include publication in media, promotional materials or social media.

Date of Birth
Day
Month
Year

I acknowledge the following rights:

  • I may decline to have my photograph published on social media platforms, thereby preventing its dissemination through various media outlets.

  • I am entitled to personal privacy.

  • I retain the right to withdraw my consent at any time, which may be done by any means of communication, including verbal notice, email, letter, or SMS.

  • I have the right to review and approve any photographs or media from specific platforms at any time, and reasonable efforts will be made to comply with this request.

  • I will be informed in advance if my image or media is to be used in new or additional ways outside the original consent.

  • My participation in photographs, video or other media is completely voluntary and will not affect my access to services or opportunities.

  • My identifying information (such as name or location) will not be shared alongside my image without my explicit permission.

  • I have the right to ask questions and receive clear information about how my image or media will be used.

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Date
Day
Month
Year

Reminder:

The referral process requires all three forms: Referrer Details, Client Consent, and Media Consent to be submitted.

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