Consent form

Consent form - MASS

MASS: Men's Accommodation & Support Services

I give my consent understanding that:other agencies may be suitable to support me to meet the needs I have identified,and would also treat my information confidentially.

My name

I agree to sharing of information between EveryMan and:

1. Name or person and/or agency

They can share information about:

2. Name or person and/or agency

They can share information about:

3. Name or person and/or agency

They can share information about:

People I would like EveryMan to talk to

I understand my workers might be able to give me better support by talking to other people. I would like them to talk to:

There are some people I don't want my information shared with.

I understand that: - this might put some limits on the support services EveryMan can give me, and - there are some situations where EveryMan can be required by law to disclose information about me (e.g. to court).

I have been given a copy of the Information for Service Users flyer

yes

not sure

Date I want this consent to start

Date I want this consent to expire

NDCA (National Data Collection Agency)

I understand that information is collected from homelessness services all over Australia. This information does not identify individuals. It tells the government about the sort of support that helps people to become independent in the way they live.

I agree to the worker completing an NDCA form using the information I give them.

Yes, I agree

No, I don't agree

Date of completing this consent form

I will confirm my consent by

a text message from my phone

a photo of me texted from my phone

sending a signed copy of this form

an email from my own address

another way

My mobile number

If you want to confirm by your phone, EveryMan will send you a message to your mobile asking you to reply or to send your photo

If you want to confirm another way, give details here:

Send me a copy of my responses

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