BCOGNITIVE Hoarding Solutions Client Consent Form

Client First Name *

Client Surname *

Date of Birth *

Address *

give consent to my support services and/or my support providers, including but not limited to my allied health professionals, support coordinator, mental health worker, and social worker, to share and exchange personal information about me.

This includes local area council representatives and government agencies (e.g. Housing SA) - where applicable.

I give this consent acknowledging that the exchange of this information is required to assist with my treatment and to assist the BCOGNITIVE Hoarding Hoarding Solutions Team in developing and enacting my hoarding recovery journey and aid in my recovery better and for them to understand my unique and personal need better.

the BCOGNITIVE Hoarding Solutions Team 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.

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

I hereby acknowledge that I am aware of my right to withdraw my consent at any time. *

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 *

Signature *

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Date *