Ballarat

reception@theshinecentre.com.au

176 Albert St, Sebastopol VIC 3356

Bacchus Marsh

admin@theshinecentre.com.au

26-28 Grant St, Bacchus Marsh VIC 3340

Phone

1300 395 747

Referral Form


Privacy Policy

Consent to Collect, Use and Disclose Personal Health Information

Client privacy is important to The Shine Centre.

The Shine Centre respects your rights and ensures all personal and health information remains private and confidential. Your health information refers to information pertaining to your health, medical history, and past and future medical care.

The Shine Centre is bound by the Privacy Act 1988 (Cth) and endeavors to uphold the Australian Privacy Principals in collecting, maintaining and storing personal medical information in a private and secure manner.

As a client of The Shine Centre, we ask that you provide us with your personal details and health information, so that we may properly assess, diagnose, treat and be proactive in your health care needs.

The Shine Centre Privacy Policy is available in hard copy at The Shine Centre.

Client Consent

We require your consent to collect, use and disclose your personal health information to provide you with safe, efficient health care. Your consent will be collected when you are registered as a patient of the practice, and this is carried-out by signing our “Consent to Collect, Use and Disclose Personal Health Information”, and verbally before any session is conducted.

You have a right to ask to alter or withdraw consent at any time. So that The Shine Centre can provide the best service possible, we need your permission to collect and store information that will help us and other services provide support to you. For instance, we may collect and store information such as your disability and health needs, clinic notes, and contact details.

Collection of personal information

Wherever possible, The Shine Centre will collect your personal information for:

  • Communications regarding treatments, and notifications about recommended preventative health care services 


  • Accounting and billing purposes 


  • The diagnosis and treatment of health conditions, including disclosure to other allied health professionals in the practice, specialists, locums and other health care providers to ensure quality care 


  • You have specifically consented to the disclosure 


  • In accordance with the Privacy Act 1988 (Cth) the disclosure is to your responsible carer, if you are physically or legally incapable of giving consent to the disclosure, or for compassionate reasons, unless there is good evidence of your wish to the contrary 


  • Where legally obliged to disclose the information (e.g. notification of certain infectious diseases, suspected child abuse) 
disclosure is necessary to prevent a serious or imminent threat to an individual’s life, health or safety or to prevent a criminal offence or seriously improper conduct 


  • It is required for judicial, administrative or coronial proceedings or is requested under a court order or subpoena 


  • It is the subject of a search warrant, or is required to help identify or locate a client

  • Accessing your personal health information


You have the right to access your personal health information. You will receive a summary of each session you have with a practitioner.

Any additional requests to access personal health information should be directed to either your treating practitioner or The Shine Centre Practice Manager. 
On receiving an application for a request to access your personal health information The Shine Centre will respond to the request for access within a reasonable period after the request is made and give access to the information in the manner requested by the individual, if it is reasonable and practicable to do so. 


Full or partial access to your health records may be refused in circumstances where:

  • Disclosure of health information may result in physical or mental harm to you or any other person the information may impact on the privacy of other individuals 


  • Information relates to existing or anticipated legal proceedings 


  • If access would prejudice negotiations with the individual 


  • Where denying access is required or authorised by law

If The Shine Centre refuses to grant access to the personal health information requested, or give access in the form requested, The Shine Centre will provide written notice that sets out:

The reasons for the refusal (except where disclosure of the reasons would be inappropriate); and 

the mechanisms available to complain about the refusal. 


Correction of personal health information

You have the right to request an amendment to your personal health information, should you believe it to contain inaccurate information. Requests to amend your personal health information should be directed to your treating practitioner or The Shine Centre Practice Manager. The Shine Centre will respond to all requests within a reasonable period after the request is made. 


There will be no charge for requesting correction of personal information. 


Where inaccurate information has been amended, you may request that The Shine Centre notify third parties in which it has previously disclosed information. The Shine Centre will take all reasonable steps to notify third parties of the correction.


If The Shine Centre refuses to correct the information requested, The Shine Centre will provide written notice that sets out: 


  • The reasons for the refusal except to the extent that it would be unreasonable to do so; and 
the mechanisms available to complain about the refusal. 


  • You have the right to decline to have your personal health information used in some of the ways outlined above, but this may limit our ability to manage your health care and to provide you with the best outcome. For more information about providing The Shine Centre with your consent to collect, use or disclose personal health information, refer to our Privacy Policy or speak with our Practice Manager. 


Consent to Collect and Share Information

By signing below, I the Client (or the parent / legal guardian / representative of the participant) acknowledge that:


  • I have read the information above and understand the reasons for why my information must be collected.

  • I understand that I am not obliged to provide any information requested of me, but failure to do so may significantly compromise the quality of health care and treatment given to me. 


  • I am aware of my rights to access the information collected about me, except in the circumstances where be legitimately withheld. I will be given an explanation in these circumstances.

  • I am aware of my right to request and amendment to information I believe is incorrect.

  • I understand that if my information is to be used for any other purpose other than that set out above, my consent will be obtained.

Note: You have a right to alter or withdraw consent at any time.  


Client Details

Parent/Guardian Details

Referrer Details (if not self-referred)


Medicare Details

This is the number next to the Client's name on the Medicare card

NDIS Details

This support category is for the provision of support coordination (understanding and using you NDIS plan to pursue your goals, connecting you with NDIS providers, community, mainstream and other government services and building your confidence and skills to use and coordinate your supports). This item can be found under 'Capacity Building' in the NDIS plan.
This support category is for the provision of specialised assessment where a participant may have complex or unclear needs, requiring long term or intensive supports to address behaviours of concern. This item can be found under 'Capacity Building' in the NDIS plan.

Reason for Referral

Shining Brighter - Parent Education Program

We have immediate availability in our Telehealth Parent Education Program. Our training series looks at areas in your child's environment that could be adapted to better support them. This includes how you communicate with your child and how that can influence your child's behaviours. 

This is a five-part series (5 x 1-hour sessions) conducted over Zoom so you can complete them in the comfort of your own home. The sessions cover topics including reinforencement, providing demands, zones of proximal development and the escalation cycle. 

Diagnosis, medical conditions, other services already engaged in, willing to attend to travel to alternate clinic

Waitlist

Please note that most services at The Shine Centre have a waitlist.  Please let us know if you are able to secure therapy services elsewhere.  At times we are able to offer last minute appointments for assessments when there is a cancellation or over school holidays.  Our reception team we will be in contact to let you know when a place becomes available.