Please Answer These Questions

Please answer YES or NO to each of the following questions.

Have you seen the What you need to know: Easy Read about getting help from Raha Community Care?YesNo

Has a Raha Community Care worker told you about your rights and responsibilities at Raha Community Care in a way you can understand?YesNo

Has a Raha Community Care worker answered any questions you might have about how we use your private information?YesNo

Do you know how to make a complaint about Raha Community Care if you are unhappy?YesNo

Is it okay if we send you newsletters or ask you if you would like to go to events?YesNo

Your Information – It's Private

When you become a Raha Community Care client, we will need some information from you.

We usually need to know:

This information will help us provide you with a good service. We will keep all your information in a personal file in a private and safe area.

Are you okay to give us this information so that we can help you?YesNo

Please write down the people or services we can also share your personal information with.

To help you think about who to list here, talk to your worker first about why a person or service might want your information.

We Can Share Your Personal Information With

Name of Person (Including Family) or Service

Sort of Help This Person or Service Provides

Type of Information

Please complete and sign this section below to give your consent to sharing this information.

Your Name

Date

Your Signature

Consent ByClientVerbal consentGuardian or other person

Witness Signature

Date (Witness)

Witness Name

Witness Role