CLIENT’S PERMISSION TO OBTAIN AND RELEASE
MEDICAL AND PERSONAL INFORMATION
Place Client Label here
Please read the following carefully and do
not sign this consent form if you do not
understand it or do not agree with its terms
I ________________________________________ Date of birth______________________
(Full name)
of ______________________________________________________________________
(Address)
Agree that the information I provide UnitingCare ReGen (ReGen) during the course of
 Triage, assessment, treatment planning & on-going care
 any other health, welfare or education service provided to me by ReGen
can be used for any purpose relating to those functions, including:





to formulate a treatment plan to address my substance use that may include sharing
information with other organisation or people providing assistance and services
to provide counselling, alcohol and other drug withdrawal treatment and on-going
care which may include discussions with other organisations and people named in
my treatment plan
in discussions with my treating doctor and/or community GP
to arrange a referral to another drug treatment service, medical practitioner,
psychiatric or psychological service, community service organisation
to keep my family or others informed of my welfare (specify name and relationship)
______________________________________________________________________
 for the preparation of a reports to
______________________________________________________________________
© UnitingCare ReGen
To be placed in Client File – Section One
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I also understand that ReGen may provide my personal information to its service
providers who assist it with archival, auditing, accounting, legal, banking, website or
technology services. ReGen may otherwise use or disclose my personal information
where required or authorised by law, which may include emergency situations and
assisting law enforcement agencies.
I understand that ReGen may not be able to provide services or support to me if I do not
provide personal information.
Client
Witness
_________________________________
Print Name
________________________________
Signature
_________________________________
Date
_________________________________
Print Name
_________________________________
Signature
_________________________________
Position
To make a request to access or correct any personal information ReGen holds about you,
please contact us using the details set out below. If you have any questions, concerns or
feedback about privacy or this form, please contact us.
Contact details:
The Privacy Officer
UnitingCare ReGen
26 Jessie Street, Coburg VIC 3058
Tel 03 9386 2876
[email protected]
www.regen.org.au
© UnitingCare ReGen
To be placed in Client File – Section One
Page 1 of 1