Patient Details

Details of Social Contact

Social & Emotional Reciprocity

Non-Verbal Responses

Maintenance of Relationships

Stereotypical Behaviours


Restricted and Fixated Interests

Reactivity to Sensory Input


Collection Statement

Allied Health Services

SASHC is required to collect and record personal information about you in order to provide quality allied health services. This may include assessing, diagnosing and providing therapy. This information is relevant to your situation, such as your  name, contact information, medical history and other relevant information as part of our service provision. This collection of personal information will be a necessary part of the assessment and/or treatment that is conducted.

Purpose of Collecting and Holding Information

All personal information gathered as part of the assessment and treatment, is kept securely.  In the interest privacy, this information is only used by therapist/s and authorised SASHC staff . Your personal information is retained for record keeping purposes and enables therapist to provide a relevant and informed service.  A more detailed description is provided in the SASHC “Privacy Policy”.   This policy is available to you on request.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation.  SASHC will discuss with you the different possible forms of access.

Disclosure of personal information

All personal information gathered by SASHC during the provision of allied health services will remain confidential, however, please note that by signing and acknowledging this document, you accept that information will be shared with other allied health professionals involved.

Please notify us if you do not wish us to disclose this information or if a court order is in place.


have read, understood and agree to the above conditions, as the authorised person completing this form. 

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