Test Please Answer These QuestionsPlease 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?YesNoHas a Raha Community Care worker told you about your rights and responsibilities at Raha Community Care in a way you can understand?YesNoHas a Raha Community Care worker answered any questions you might have about how we use your private information?YesNoDo you know how to make a complaint about Raha Community Care if you are unhappy?YesNoIs it okay if we send you newsletters or ask you if you would like to go to events?YesNoYour Information – It's PrivateWhen you become a Raha Community Care client, we will need some information from you.We usually need to know:your name and your contact detailsyour family, carer or support person’s contact detailssome information about your health and wellbeingThis 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?YesNoPeople or Services We Can Share Your Personal Information WithPlease 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 WithName of Person (Including Family) or ServiceSort of Help This Person or Service ProvidesType of InformationConsent to Sharing InformationPlease complete and sign this section below to give your consent to sharing this information.Your NameDateYour SignatureYour browser does not support e-Signature field.Raha Community Care Worker – To Complete Section BelowConsent ByClientVerbal consentGuardian or other personWitness SignatureYour browser does not support e-Signature field.Date (Witness)Witness NameWitness RoleSubmit Consent
