The Diverse Collective Consent Form

Consent to Obtain, Record and Share Information

Please complete and sign this form to give The Diverse Collective (TDC) consent to obtain, record and share your information on your behalf. The information we will share will depend on the consent you give us on this form. For example, you can agree to us sharing information to a third party about:

you
your plan or your funded supports
your medical reports held by us
incidents, near-misses or similar
changes to your supports or situations
your contact details
photographs
de-identified information for research
medical appointments or similar

You do not have to give your consent if you do not want to share your information. If you give us consent and then decide that you do not want us to share your information anymore, you can withdraw or amend your consent by contacting us at:

hr@thediversecollective.com.au or;
1300 440 274

We will not share your personal information with anyone unless you have given your consent for us to do so or the disclosure of your information is required by law.

Note: If you are not the participant and you are a child representative, plan nominee or legally appointed decision maker, please ensure to complete Part B of this form.

Part A: Participant details

First name *

Last name *

Date of birth *

NDIS Number *

Phone Number *

Part B: Child representative, plan nominee, legally appointed decision maker details

Please provide your details in this section if you are completing this form on behalf of a Participant:

under 18 years for whom you have parental responsibility, or a child representative
for whom you are a plan nominee, or
for whom you are a legally appointed decision maker (for example, a guardian).

The Diverse Collective may ask you to provide evidence that you are authorised to represent the Participant and identification to verify your identity.

Please mark the relevant box below to indicate your relationship to the participant

Child representativePlan nomineeLegally appointed decision makerOther

Participant Representative Full Name (as per government issued ID)

Participant Representative Residential Address

Participant Representative Date of Birth

Participant Representative Phone Number

Participant Representative Email Address

I consent to The Diverse Collective obtaining and sharing information about me (or the participant I am representing who is identified in Part A of this form), to the following people and organisations.

Part C: Consent Agreement

3.1 The Participant and/or The Participants legal representative gives the following consent for TDC to share, obtain, collect and store information required to deliver services.

3.1a Please mark the relevant boxes below to indicate the information you give consent to share with TDC.

My personal information *

My name, date of birth, NDIS participant number and NDIS participant statusMy address, email and phone numberDetails about my CarersDetails about my Informal supportsDetails about my Service Providers and/or Medical Care Team

Reports *

Assessments and reports A copy of my current NDIS Plan

Any other information

If so, please specify what this information is below:

3.1c Please mark the relevant box below to indicate the length of time you are providing consent

Ongoing

For the duration of my current NDIS plan

For a set time ending (DD/MM/YYYY)

Once only

Part D: Your declaration

Please note: NDIS participants’ aged 18 and over have other options instead of signing this consent form.

If you are unable to sign in Part D, you may provide verbal consent to The Diverse Collective, or
You can direct someone aged 18 and over to sign (your ‘delegate’) in the presence of a witness.

If you direct a delegate to sign on your behalf, your delegate and witness needs to complete Part E. Otherwise, please sign, below.

By signing this consent form (please mark each box below):

I understand I can obtain further information about how The Diverse Collective handles my personal information from the Privacy Policy on their website. You can find this information at www.thediversecollective.com.au

*

I understand I have given The Diverse Collective consent to share information about me to third parties but only when it is necessary to deliver the services I need and lawful.

*

I understand I can withdraw or change my consent at any time.

*

Signature

Draw signature|Type signatureClear

Name *

Date *

If you are not the participant, please mark the relevant box below to indicate your relationship to the participant

Child representativePlan nomineeLegally appointed decision maker (please provide the NDIA with details of this appointment if not already provided)

Part E: Your Delegate's declaration

Please note: This section is only to be completed if you, the Participant, are unable to sign this form in Part D. Instead, you have chosen a ’delegate’. Your delegate must be aged 18 and over and must sign in the presence of a witness.

Full name of Delegate

Delegate's contact number

Signature of Delegate

Draw signature|Type signatureClear

Date

Witness Full Name

Witness contact number

Witness Signature

Draw signature|Type signatureClear

Date of witness signature

Privacy and your personal information

Collection of your personal information

The Diverse Collective (TDC) requires some personal information from you so we can provide you a service. Any personal information you provide to TDC is safe under the National Disability Insurance Scheme Act 2013 and the Privacy Act 1988. You can also ask to see what personal information we hold about you at any time and can seek correction if the information is wrong.

Personal information use and disclosure

TDC will use your information to support your involvement in the NDIS and with our service.

TDC will not use any of your personal information for any other purpose, or disclose your personal information to any other organisations or individuals (including any overseas recipients), unless authorised by law or you provide your consent for us to do so.

TDC's privacy policy describes

how we use your personal information.
why some personal information may be given to other organisations from time to time.
how you can access the personal information we have about you on our system.
how you can complain about a privacy breach, and how TDC deals with the complaint.
how you can get your personal information corrected if it is wrong.

You can find the policy at our website http://www.thediversecollective.com.au

Personal information storage

TDC uses an external and reputable company to secure all data and for storage of personal information. System users, other than TDC staff, may at times be able to see your name when they perform mandatory duties, however they can’t record, use or disclose information. State or territory government officials may also have personal information access as part of the agreement between governments and NDIS Providers to uphold their obligations under the NDIS and Privacy Act. Third parties also include external auditors.

Save and Complete Later