Representative Consent

Client Details

Client first name *

Client last name *

Client email *

Client mobile *

Client date of birth *

Client address *

House number and street *

Suburb *

State *

Postcode *

Please indicate if you would like to nominate representatives to receive communication relating to your Hear and Say Service. You will be included in all communications. *

YesNo

Primary Representative Details

Primary representative/carer first name *

Primary representative/carer last name *

Primary representative/carer email *

Primary representative/carer mobile *

Primary representative/carer address

House number and street

Suburb

State

Postcode

Would you like to list an additional representative/carer?

YesNo

Secondary Representative Details

Secondary representative/carer first name *

Secondary representative/carer last name *

Secondary representative/carer email *

Secondary representative/carer mobile *

Research Consent

We work in collaboration with world-class researchers to advance our knowledge and provide the evidence-base to underpin our work and improve outcomes of our adult clients, children and families.

By indicating my consent and signing this form, I grant permission for the following general research-related activities that have been approved by the Hear and Say Research and Ethical Advisory Committee:

Access to my/my child’s medical, speech, language and hearing data that are documented in my/my child’s file.
Data sharing of my/my child’s results between projects.
Data sharing with First Voice, a national and global alliance of which Hear and Say is a member.

In doing so, I understand that:

No identifying information regarding my child or myself will be divulged; that any data collected will not be published or presented as to reveal my/our identity; and my/our privacy will be maintained at all times.
My/our participation is completely voluntary and that I may terminate my/our involvement in the studies at any time, without this affecting my/my child’s ongoing enrolment at Hear and Say.
Although the purpose of the research projects is to improve the quality of services for adults and children with hearing impairment, our involvement in the research may not result in any direct benefit to myself or my child.
Separate consent will be sought from me for inclusion in any research projects requiring active participation by me and/or my child.
I have the opportunity to raise any particular concerns relevant to the participation of my child and/or myself in research and to request project updates.

I grant permission for general research-related activities that have been approved by the Hear and Say Research and Ethical Advisory Committee.I do not give research consent.

Telepractice Consent

Under certain circumstances, Hear and Say may offer the opportunity for telepractice-based (online) consultations instead of in-person with a clinician.

We will not provide personal information to any other individuals or organisations without prior consent except where required by law to do so. At times, we may also disclose information on a confidential basis with:

Your clinician/specialist must maintain confidentiality and privacy standards during sessions, and in creating, keeping and transmitting records.
At times, audio and video recordings of sessions may be taken to support the clinician/specialist’s work, as may occur in centre-based consultation. You will be informed before a recording takes place and can refuse to be recorded for any reason. Your clinician/specialist will inform you of the reason for the recording and how it will be stored and used.
While your clinician/specialist is obligated to meet standards to protect your privacy and security, telecommunication, including videoconference, may increase exposure to hacking and other online risks; as with all online activities, there is no guarantee of complete privacy and security protection. You may decrease the risk by using a secure internet connection, meeting with your clinician/specialist from a private location, and only communicating using secure channels.
You can ask about alternatives to telepractice at any time. If you refuse or change your mind about telepractice services, your clinician/specialist can discuss any other options with you. Your clinician/specialist may or may not be able to offer alternative services.

I agree to receive services via telepractice as applicable. I understand that I may agree or refuse any service or part of a service at any time. I can agree or refuse in writing or verbally.I do not give telepractice consent.

Photos and Videos Consent

I give permission for Hear and Say and affiliates to take photographs and/or video recordings of my/our child and siblings, and myself/ourselves during events and activities organised or provided by Hear and Say. I understand that the photographs and/or video recordings may be used and published by Hear and Say and their partners (e.g. at our events) on platforms which may include our website, social media, press releases, reports, resources and collateral, and funding agreements.I do not give photos and videos consent.

Sharing of Information Consent

Hear and Say is committed to ensuring the protection of your personal information. The following summary outlines how we collect, handle, store, and disclose your personal information, in accordance with applicable privacy laws and best practice standards.

1. Collection, Use, and Disclosure of Personal Information

We will collect, hold, and use your personal information to provide you with relevant services, including but not limited to:

Early Intervention (Listening and spoken Language Therapy)
Audiological (Hearing) Management
Medical Management
Allied Health Services
Rehabilitation/Habilitation
Speech Pathology
Group programs
Associated Administrative Purposes (such as external auditing)

We may collect personal information from external providers as part of the above services.

2. Protection of Personal Information

We take reasonable steps to ensure that your personal information is protected from misuse, interference, and loss, as well as unauthorised access, modification, or disclosure.

3. Disclosure of Personal Information

We will not provide your personal information to any other individuals or organisations without your prior consent, except where required or authorised by law. However, we may disclose personal information on a confidential basis to the following parties:

Contractors: We may share information with contractors who assist Hear and Say with services such as database management, printing, and mailing.
Overseas Recipients: In certain situations, we may disclose your information to overseas recipients, for example, a medical practitioner in another country, if you are using our health services and reside outside Australia.
Emergency Services: In the event of an emergency, we may disclose your personal information to relevant emergency services personnel.

4. Your Rights

You have the right to request access to your personal information and to ask for it to be corrected if it is inaccurate, out of date, incomplete, or misleading.

5. Consent

I give permission to collect and share personal information with the relevant parties involved. I understand, acknowledge, and agree to be bound by the terms set out in this form. *

I give permission for this information to be shared/distributed via email. *

I acknowledge that I have read the Privacy Policy. *

Name of signatory *

Signature *

Draw signature|Type signatureClear