By completing this form: I (the client) understand Indigo will collect, store, use and disclose my personal information for the purpose of providing me a service.
I (the client) am aware that my details will be kept securely, and will only be shared with others for the purpose of delivering my service.
I (the client) understand that before discussing any of my personal information, Indigo will ensure that the person making contact is myself or an authorised person.
If you answer no to either of the above questions, this may prevent us from being able to assist you fully or provide you with the specialist service you are seeking from our organisation.
We are unable to provide you with this specialist service if we do not have your consent to continue.
Consent:Consent means giving permission for something to happen. It means you agree that someone can do something.
Indigo collects, holds, uses and discloses personal information for different reasons, including:
What information do we collect about you?Indigo will only collect, hold, use and share personal information that is needed to delivering services. Personal information usually includes details like your name, address and date of birth. Indigo may ask to collect sensitive information like health information, or racial and ethnic origins.
Indigo will always ask before collecting your information. If you cannot physically or legally give consent, a responsible person (like a family member or guardian) may provide consent on your behalf.
Consent can be withdrawn at anytime. We may need to stop services if you withdraw consent. How do we collect personal information?As far as possible, Indigo will collect personal information from you directly via the phone, email, or in person. Where this would be unreasonable or impracticable, information may be collected from someone else. Personal information that is sensitive information can only be collected with your consent, unless collection is required or authorised by law.Providing Indigo with personal information about someone elseIf you are making an enquiry or referral on behalf of another person, then you should only do so if you have their consent to provide us with their personal information. Please share this Privacy Statement with the person concerned, before sharing their personal information.
How is personal information stored and secured?Indigo holds your personal information in:
We take reasonable steps to:
Sharing your personal informationIndigo respects your privacy and we will take reasonable steps to keep your personal information strictly confidential.
People who work at Indigo will not share your personal information with someone else, including overseas people or organisations, without your consent.How do I access and update my personal information?If you wish to access your personal information or you believe the information Indigo has about you is not correct, not up-to-date, not complete, not relevant, or misleading, please contact us via one of the methods listed below.
Email: firstname.lastname@example.orgMail: Quality and Risk Professional, Indigo, ‘The Niche’, Suite A, 11 Aberdare Road, Nedlands WA 6009Telephone: (08) 9381 0603 Fax: (08) 9381 0611
A copy of this form will be sent to this address when submitted
Phone and/or email
Please provide the details of the therapist helping with this hire (ensure you have consent to provide their information)
Street address only. (Will not be shipped to a PO Box)
Please select one option from the list of supports.
*DISCLAIMER* Support offered cannot replace the support of the client's regular therapist.
Before completing the 'AAC Hire Service Form' you will need to submit a request for services to:
Please Note: This referral will be valid for 6 months
As consent has not been given to your information being collected, stored, used and disclosed for the purpose of providing you with a service, Indigo is unable to process your referral at this time.
To discuss further please contact us on 08 9381 0600
You can navigate away from this page or use the Submit button without any personal information being recorded by this service.