Consent Form

Exchange of Information Consent Form People & Agencies List

FLourish Speech Pathology Services (“we”, “our”, “us”) follows the South Australia Government Information Sharing Guidelines for Promoting Safety and Wellbeing (ISG). We will work closely with other agencies to coordinate the best support for you and your family. Under the ISG your informed consent for the sharing of information will be sought and respected in all situations unless: 1) It is unsafe or impossible to gain consent or consent has been refused; and 2) Without information being shared, it is anticipated a child, young person or adult will be at risk of serious harm, abuse or neglect, or pose a risk to their own or public safety.

To ensure the effective provision of services, we may disclose and exchange personal information (which includes health information) with the following people and/or agencies:

• Department of Education SA & schools/preschools

• Department of Child Protection

• Catholic Education Office & schools/preschools

• Child and Youth Health

• Association of Independent Schools (SA) & schools/preschools

• Department of Human Services

• Children and Adolescent Mental Health Services

• National Disability Insurance Agency

• Any other people and/or organisations specifically nominated by you

For individuals aged 18 and above, information will be exchanged and disclosed to your parent(s) and/or legal guardian(s) unless consent is specifically withdrawn.

You can withdraw consent (including on behalf of another, if you are a parent/guardian of a child under 18 or the parent/guardian of a client over 18 who is unable to provide consent independently), for us to exchange or disclose information with any of the people and/or agencies listed above by notifying us in writing. However, please note that is you do so, we may not be able to provide a full range of services.

I (client/parent/guardian/carer) give permission for FLourish Speech Pathology Services to contact the following organisations or persons to obtain/exchange information regarding myself/client named above, to assist with the provision of a quality service:

This form will remain current from the date of signing until you withdraw consent or complete a new form. The form will be retained in the client's file.