Client Intake Form

CLIENT INTAKE FORM









Birthdate:

Are you Aboriginal or Torres Strait Is?:

Residency Status:

Occupation:

Private Health Insurance:

Insurance provider:

What situation brought you here today?:

Relationship Status:

Religion:

How did you hear about Eva’s Place?:

Assistance:

Agency name:

By submitting this form, you agree to the confidentiality conditions below.

Your confidentiality is very important to us. The Privacy Act (1988) covers the collection, storage and release of information.

  • NONE of your personal information, including verification that you have contacted us, can be shared outside our organisation without your express consent.
  • NO information you provide will be released to anyone or any organisation without your consent.
  • In rare circumstances, our duty of care for you, or the law, may require us to disclose information to another organisation or authority (e.g. police) if your safety or the safety of others is at risk.
  • More than one worker at Eva’s Place may have access to your file because we operate in a team environment. This is to offer you the best support possible and is not a breach of confidentiality.

If you have questions or concerns about our confidentiality and privacy policy, please ask our staff for assistance.