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Mackay QLD 4740
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Referral Agency Details
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Client Details
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Referral agency:
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Referral agency contact person/details:
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Name:
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Position:
Client Details:
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First
Last
Date of Birth:
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Address:
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Contact Number:
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some information will be recorded about me that a service can provided
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I can ask to see the personal information recorded about me
Information will not be shared with others without my consent (except for duty of care reasons, as explained to me)
I can withdraw my consent at any time.
Consent to collect and disclose
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I understand that YIRS may need to collect and disclose personal information to third parties in order to provide me with support. I nominate that my personal information be disclosed only to the right person/s or agencies listed below:
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This consent relates to the following specific personal information of type of information:
I consent to the stated personal information being discussed with /released to the following organisations and/or individuals:
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I consent to the stated personal information being released to / discussed with the nominated organisations or persons for the following purpose/s:
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I consent to the stated personal information being released to / discussed with the nominated organisations or persons for the following purpose/s:
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Aware Withdraw Consent
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I am aware that I may withdraw this consent, or part of it, at anytime by telling YIRS that I do not consent to further release of information about me.
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