CONSENT & CONTACTS UPDATE

Are you completing this for yourself or as a parent/guardian? *

SelfParentGuardian

Child's Name *

First Name *

Last Name *

Date of Birth *

Mobile Number

Email Address

What would you like to update?

Add/Update ConsentWithdraw ConsentUpdate Personal Details

CONSENT TO SHARE INFORMATION WITH OTHERS

GP CONSENT

GP Name *

Practice Name *

Practice Email Address (if known)

Remove Consent for Previous GP if on file?

PSYCHIATRIST/PAEDIATRICIAN CONSENT

Psychiatrist / Paediatrician Name *

Email Address (if known)

Remove Consent for previous Specialist if on file?

NDIS SUPPORT COORDINATOR CONSENT

Support Co-ordinator Name *

Email Address *

Phone Contact

What Information can we share with your Coordinator?

Any Limits on what we can share?

Remove Consent for previous Support Coordinator

NDIS PLAN MANAGER CONSENT

NDIS Plan Manager Name *

NDIS Plan Manager Email Address

What information can we share with them?

Any limitations on what we can share with them?

SCHOOL / TEACHER / SCHOOL COUNSELLOR CONSENT

School *

Teacher Name *

Email Address

Phone Contact Number

What information can we share with them?

Any limits on what we can share?

LEGAL REPRESENTATIVE CONSENT

Legal Representative Name *

Legal Firm *

Email Address

Phone Contact

What information can we share with them?

Any limits on what we can share?

INSURER & CASE MANAGER CONSENT

Insurer Name *

Case Manager Name

Email Address

Phone Contact

What information can we share with them?

Any limits on what we can share with them?

FAMILY MEMBER / PARTNER / CARER CONSENT

Name of Family Member/Partner/Carer *

Relationship

Email Address

Phone Contact

What information can we share with them?

Any limits on what we can share

OTHER PROFESSIONAL CONSENT

Other Professional Name

Organisation

Email Address

Phone Contact

What information can we share with them?

Any limits on what we can share?

WITHDRAW/REMOVE CONSENT

Which consent would you like to withdraw?

I understand Jon Grainger Psychology will no longer communicate with the selected party unless required by law

Update Personal Details

Address

Street address

City

State

Postcode

Phone Number

Email Address

Medicare Card Number

NDIS Funding Details

Emergency ContactPlease provide full name, relationship and contact details

OtherPlease provide detail

Change of Name Supporting Documents (eg: Drivers Licence, Medicare Card or Change of Name Certificate

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DECLARATIONS & SIGNATURE

I confirm the information provided is accurate *

I understand I can withdraw or change consent at any time by completing the form again or notifying the practice in writing *

Signature *

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Date *

Full Name of Person Completing this Form *

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