Family Wellbeing - Baptist Care SA

1Consent

2Personal Details

3Essential General Ref.

4Authorisation

Consent*
I agree to the privacy policy.
Baptist Care SA complies with the Privacy Amendment (Enhancing Privacy Protection) Act 2012 and government guidelines*, which set out the rules for handling your personal information. These require Baptist Care SA to have your consent to collect, store and disclose your personal information.

At Baptist Care SA, your personal information:

• is collected and used for the purpose of providing you with a service that is individually suited to you.
• will be stored securely.
• will not be passed to third parties, unless with your express written permission; except when requested by the relevant authorities to protect people (including children) from harm or abuse; or when a person is at risk and for the purpose of providing unidentified data only to the Department of Social Services who fund this program.
• may be accessed by staff associated with your service delivery.
• may be viewed by external auditors to assist with improving the quality of the services provided.
• can be seen by you, at your request through the Freedom of Information Act 1982
• you can withdraw your consent at any time. However, once consent is withdrawn, we are no longer able to offer you services.

Do you consent to this? Please sign the consent on the last page of this document once you have filled out all of the information required within. Filling out all the information as best you can, will help us to expedite your referral to the intake process. Otherwise, your referral could be delayed in getting to the intake team.

If upon receiving the referral form, we identify that the information required for service provision is incomplete, you understand that the referrer and/or parent/guardian will be contacted by one of our administrative staff to complete the referral form, so that it can be sent through to the intake team.

The referral process is to ensure that all relevant information has been provided. This process does not guarantee eligibility to our service.

While eligibility to our service is being assessed, an information pack will be sent out, containing resources on how we can work together in the best interests of children/ young persons, followed by the full consent forms.

Please read them and let us know if you have any questions or concerns. Remember you can withdraw consent and exit our services at any time.

* information collected and used by Baptist Care SA and the Family Wellbeing Service for demographical and statistical reporting purposes, on behalf of the Department of Social Services.

Client Name*
First Last
Gender*
- Male
- Female
- Other
Date of Birth*
DD slash MM slash YYYY
Age*
Other children in this family?*
- Yes
- No
If last name is different, please specify
Details of other children in this family
Full Name Gender Age DOB

Please add all details of other children in the family.
Main Address of Client*
Street Address City ZIP / Postal Code
Parent / Guardian Name*
First Last
Main Contact Number*
Main Email*

PERMISSION TO RELEASE INFORMATION*
I understand that making a referral and going through to the Intake Team does not guarantee eligibility to the FWS. I will be required to attend an assessment call/ meeting to discuss my personal situation and circumstances, before being able to register in Family Wellbeing Services. In addition, if at any time during my engagement with the service, it is deemed that my needs do not fit into the category of early intervention and prevention of mental health issues, I understand that it may be necessary for all persons referred to be transitioned to a more suitable service. By signing this form, I acknowledge that I have read and understood the information contained on this referral. I am consenting to the information provided within this document to be given to Baptist Care (SA), for the purpose of being contacted for an assessment for Family Wellbeing Services. In the case that I am eligible to receive support through the service, I hereby give consent to all of the personal information that is recorded on this referral form to be collected and used by Baptist Care SA and the Family Wellbeing Service, for demographical and statistical reporting purposes, on behalf of the Department of Social Services.
- Yes
- No
Name*
First Last
Date*
MM slash DD slash YYYY
View our Privacy Policy.
CAPTCHA

At Baptist Care SA, we recognise all people are connected to a wider network of relationships that include family, friends and community.

To access our services, please complete this referral form:

Eligibility Essential Criteria

Other

Client`s Additional Details:

Main Carer Details

Second Carer Details

To be filled in by the referrer

Full Name	Gender	Age	DOB