Future Footprints Consumer Registration Form

Consumer’s Information

Emergency/ Secondary Contact Information

Details of Referring Professional
(if the Consumer is referred by another service provider)

Details of General Practitioner

Details of other Relevant Medical Specialists

Medical Information

Future Footprints Consumer Intake Questionnaire

Current level of Physical Function:

Current Cognitive Function:

Likes / Dislikes / Personality

Consent to Collect and Release Information Form

Future Footprints Conductive Education respects the rights of individuals and their families to privacy. To enable Future Footprints Conductive Education to provide your / your family with a quality service, we need to collect some personal information from you. To do this we require your consent.

When you first register with Future Footprints Conductive Education as a Consumer of our services we will request that you complete this Consent to Release / Request Information Form. A Future Footprints staff member will explain the form to you. You have a right to withdraw or limit consent at any time. However, this may make it very difficult for Future Footprints Conductive Education to provide the appropriate services to you / your family.

The information you provide us with, will also be used for:

• The administrative purpose of running Future Footprints Conductive Education,
• Billing either directly or through a funding body,
• Discussing or passing your case to another practitioner within the organisation for your ongoing management,
• Disclosure of information to your doctors, specialists, other health professionals or to teachers to facilitate communication and best possible care for you,
• In the case of insurance or compensation claim it may be necessary to disclose and/or collect information that concerns your functional health status.
• In the case of compliance with the NDIS Commission’s rules regarding incident management, complaints or reporting the use of restrictive practices.

Future Footprints will work closely with other agencies to coordinate the best support for you / your child. 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.

Future Footprints Conductive Education has a Privacy Policy that is available on request. This policy is guided by key legislation including (but not limited to) the Privacy Act (1988) and NDIS Code of Conduct and provides detailed guidelines on the collection, use, disclosure and security of your information; advises how you may request access to, and correction of, your personal information; and how you may complain about a breach of your privacy and how we will deal with such a complaint.

Keeping children safe is an important role of all community service providers. If there are any concerns regarding a child’s safety, welfare or wellbeing, Future Footprints Conductive Education may be legally obligated to disclose information without parental consent under Chapter 16A of the Children and Young Persons (Care and Protection) Act 1998. In accordance with the principles of the Children and Young Persons (Care and Protection) Act 1998, wherever a child or young person is able to form his or her own views on a matter concerning his or her safety, welfare and well-being, he or she must be given an opportunity to express those views freely and those views are to be given due weight in accordance with the developmental capacity of the child or young person and the circumstances. Therefore, a child’s capacity to provide consent should be considered on an individual basis.

If you need any further information or have any questions or concerns about the collection and use of your personal information, please discuss with a Future Footprints staff member.

have read the above information and understand the reasons for the collection of my or my child’s personal information and the ways in which the information may be used and disclosed, and I agree to that use and disclosure.

• I understand that it is my choice as to what information I provide, and that withholding or falsifying information might act against the best interests of my or my child’s assessment and therapy progress.
• I am aware that I can access my or my child’s personal and treatment information on request and if necessary, correct information that I believe to be inaccurate.
• I understand that if, in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me.
• I have been given an opportunity to obtain a copy of Future Footprints Conductive Education’s Privacy Policy.

I authorise for Future Footprints Conductive Education to:

• Request and obtain my or my child’s personal information from the following health professionals, service providers and organisations
• Exchange my or my child’s personal information with and between the health professionals, service providers and organisations below.

I understand that my consent will continue until I advise Future Footprints Conductive Education in writing or verbally that I withdraw my consent.