Youth Support Intake Form (Page 3 of 3) in pdf

Youth Support Intake Form Page 3

Consent from Client:

I consent to this referral occurring and agree that the above named referrer make contact with Mornington Peninsula

Shire Youth Services Program. I acknowledge that no other support service, person or agency will be contacted

however give Mornington Peninsula Shire Youth Services Program consent in making contact with me for further

information/support. I understand that the information collected on this form will be kept confidential and not

discussed outside of the Mornington Peninsula Shire Youth Services Program, unless I otherwise authorise.

Signature: ________________________________________________ Date: ________________________

Consent without client present:

I understand that the information provided on the referral form may only be used for the purposes to Mornington

Peninsula Shire Youth Services Program. The referee has given me verbal consent to provide this information and

they would be willing for Mornington Peninsula Shire Youth Services Program to make contact with them to gain more

information/support. Consent has not been given to make any contact with other services for any other purposes. I

agree to keep the above information confidential and not discuss it outside of the Mornington Peninsula Shire Youth

Services Program.

Signature: ________________________________________________ Date: ________________________

Youth Support Intake Form Page 3