COLLECTION AND USE OF YOUR PERSONAL INFORMATION
headspace Gold Coast collects personal information from you for the purpose of
providing quality health care and for administration purposes such as accounts. As
we require your consent to collect this personal information, it is important that you
read this document carefully and sign where indicated below.
We will use the information you provide in the following ways:
1. Medical / Psychological
You will be asked to give headspace some personal and medical details as well
as some information about your family, so that your headspace worker can
understand your situation and properly assess, diagnose, treat and plan your
healthcare where required.
There may be situations where this may involve passing on some personal
information to others involved in your care. For example:
Doctors or Specialists outside headspace Gold Coast, should you require
ongoing medical tests or referral. Referral to other Practitioners is usually
via a written report, typed by staff from this service. All headspace Gold
Coast staff are bound by their headspace obligation to maintain your
privacy.
Pathology data to specific pharmaceutical monitoring bodies.
Another headspace worker at this clinic if you agree to see more than one
headspace worker, or if your regular headspace worker is likely to be
away for any length of time.
2. Administration
For administration and billing purposes for the effective running of headspace
Gold Coast and to comply with Medicare and Health Insurance Commission
requirements.
3. Data Collection
For research and or statistical purposes headspace Gold Coast provides non
identifiable data (no names or personal contact details are provided) to
headspace National. No individual can be recognised through this type of data.
CONFIDENTIALITY
It is our wish to provide you with quality care and services. As part of this headspace
Gold Coast has developed a policy to protect patient privacy in compliance with
privacy legislation. The provision of quality health care requires a headspace worker-
participant relationship of trust and confidentiality. This is most successful when you
feel as though you can tell us any information about your situation without feeling
frightened or embarrassed.
For this reason, nearly all of the personal information that you choose to tell us will be
kept confidential. This means that the things we talk about during our counselling
sessions won’t be shared with any other people without your consent. This includes
family, friends, and other headspace staff.
However, there are 3 occasions where we MUST tell someone what you might have
told us. These are:
1. If the safety of yourself or other people is threatened
2. If you tell us about future illegal activities
3. If you threaten the welfare of anyone or any property at headspace Gold
Coast
In these situations we are obligated to inform the Manager of headspace Gold
Coast. Your safety and the community’s safety are our primary concern.
If you have any questions regarding confidentiality, please ask now.
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CONSENT FORM
I have read and understand the headspace policy on collection and use of my
personal information on page 1. I have read and understand how headspace will
treat my information confidentially and the 3 occasions where confidentiality must be
broken. I agree to my personal information being used as explained on page 1 of this
document.
I am aware that headspace Gold Coast has a Privacy policy which covers the
collection, storage, disclosure and security of patient information. The Policy
conforms to the Privacy Act and Health Records Act and all other relevant
Government laws and regulations.
I agree to the information I provide being used to assess and plan for the types of
support services that headspace Gold Coast might provide and that this will be
discussed with me before further services are arranged. I understand that I am not
obliged to provide the information requested of me, but my failure to do so might
compromise the quality of health care and treatment given to me.
I am aware of my right to request access to the information collected about me and
request amendment if l believe it to be inaccurate. I understand that in some
circumstances access might be legitimately withheld, however, l will be given an
explanation in these circumstances.
I understand that if my information is to be used for any purpose other than set out
above, this will be explained to me and l will be asked if l will give my permission. I
understand l have the right to refuse.
You:
Signed: ___________________________________________
Please print your name: ____________________ Date: _____________________
If you are under 18 years old you may also need to have an adult guardian read and
sign the guardian section below.
Guardian:
I have read and understood the above information about confidentiality. I also
understand that all other information concerning this young person will not be
disclosed to any other person or agency unless there is a joint decision to disclose
that information by the young person and the counsellor.
Signed: ________________________ Print name: ________________________
Date: _____________ Relation to Participant: ____________________________
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