Hope&Ability Pty Ltd is committed to protecting your privacy and handling your personal information in accordance with the Privacy Act 1988 (Cth), the Australian Privacy Principles (APPs), and all other applicable privacy legislation.

By submitting this referral or intake form, you acknowledge that Hope & Ability will collect personal and, where applicable, sensitive health information about the participant for the purpose of assessing the referral, determining service suitability, providing allied health services, coordinating care, administering appointments, processing invoices, meeting legal and professional obligations, and complying with NDIS requirements.

The information we may collect includes, but is not limited to:

• Participant and guardian contact details

• Date of birth and identifying information

• NDIS information, including plan details and funding arrangements

• Medical history, diagnoses, medications, and relevant health information

• Behavioural, psychological, educational and functional information

• Emergency contact details

• Information relating to support networks, schools, employers and other service providers

• Reports and supporting documentation uploaded through this form

Where necessary and with appropriate consent or legal authority, your information may be shared with relevant parties involved in your care or funding, including:

• Support Coordinators

• Plan Managers

• The National Disability Insurance Agency (NDIA)

• Treating General Practitioners and medical specialists

• Allied health professionals

• Schools, childcare services or educational settings where required with authorization

• Hospitals or emergency services where required

• Government agencies where disclosure is authorised or required by law

Hope & Ability stores personal information using secure electronic practice management systems and implements reasonable administrative, technical and physical safeguards to protect information from unauthorised access, loss, misuse or disclosure.

You may request access to or correction of your personal information by contacting Hope & Ability. Further information about how we collect, use, disclose and protect personal information is available in our full Privacy Policy.

Participant Declaration and Consent

By submitting this form, I acknowledge and agree that:

☐ I have read and understood the Hope & Ability Privacy Policy.

☐ I consent to Hope & Ability collecting, storing, using and disclosing my personal and sensitive information (or the participant's information where I am authorised to act on their behalf) for the purposes of assessing this referral, providing services, coordinating care, communicating with relevant stakeholders, processing funding and invoices, and complying with legal, professional and NDIS requirements.

☐ I understand that information may be shared with relevant healthcare professionals, schools, support coordinators, plan managers, the NDIA, funding bodies and other organisations involved in the participant's care where appropriate, authorised or required by law.

☐ I confirm that the information I have provided is accurate and complete to the best of my knowledge.

☐ Where I am completing this form on behalf of another person, I confirm that I have the legal authority or appropriate consent to provide this information and to consent to the collection and use of their personal information.

☐ I understand that submitting this referral or intake form does not guarantee acceptance of the referral or commencement of services. Hope & Ability will review the referral and contact me regarding the outcome.