Participant Consent Form

NDIS Participant Consent Form
Date

MonthDayYear
Date
Name of participant
Is the participant providing consent?

YesNo
Is an authorised person providing consent?

YesNo
If yes, name of authorised person
Relationship to the participant
How did you hear about Dokotela?
Please tick the following boxes to indicate where you give your consent
Consent to take photos and videos, and provide feedback to external auditors:

Consent to record you on audio or visual devices - we will inform you if we want to do so each time. Photos and videos may be used for promotional purposes. For example,we may publish your photo or video on social media or our website.Consent to provide feedback to other people about the services you receive from us. This includes NDIS auditors. You may say no at any time, and that will be documented in your file.
Consent for us to collect information from you:

To collect information about your disability, medical history, living arrangements, support arrangements, and other information such as your cultural needs, so we can continue to deliver services to you that enhance your well-being.We are asking permission to take photos of you for the purposes of identification in your files.
How we will secure your information: we will store that information in secure electronic files and in locked paper storage. Only people authorised to access your information can do so.
Consent for us to share information about you to other providers or individuals

I give consent for Dokotela to share my information with the following people or services. I understand that sharing information may include discussing my support needs, reviewing any incidents that have occurred, and providing training (where relevant) to the people or providers listed below:

	Please provide name of person or provider.	Contact Details
1
2
3
4
5
6
7
8
9

Consent for us to share information about you to other providers or individuals

I do not give consent for Dokotela to share my information with the following people or services:

	Please provide name of person or provider.	Contact Details
1
2
3
4

With your permission we may also need to disclose information to other people when it is in your best interest. We may have to disclose some information without your permission if we are required to by law.
How do I withdraw my consent?

It's important to know that this consent can be withdrawn at any time. You can withdraw your consent by writing to us. You can do this by sending us an email, a letter, or a text.

How long will this consent last?

This consent form will last for one (1 year) unless you choose to withdraw consent.
Signature of participant/ authorised representative

Clear
Name of participant / authorised representative
Date

MonthDayYear
Date
Signature of Dokotela Representative
Name of Dokotela Representative

Kim Daly
Date

MonthDayYear
Date
Should be Empty:

NDIS Participant Consent Form

Please tick the following boxes to indicate where you give your consent