RAINBOW MEMBERSHIP FORM

Welcome to

A safe and friendly place for all Canberrans living with a mental illness

☐New Membership ☐Membership Renewal

NDIS REGISTRATION NUMBER:

Personal Details

Name / Date of Birth
Preferred Name / ☐Male☐Female
Address / Postcode
Does the person identify with either of these cultural backgrounds? / ☐Aboriginal or Torres Strait Islander
☐Diverse Cultural and Linguistic Background
Country of Birth / Preferred Language
Phone / Email

NDIS Details

Are you an NDIS recipient? / Yes / ☐ / No / ☐ / Do you have a Service Level Agreement with MHF? / Yes / ☐ / No / ☐ /
Would you like help with applying for NDIS support? / Yes / ☐ / No / ☐ / Are you utilising an MHF service currently under an NDIS plan? / Yes / ☐ / No / ☐ /

Emergency Contact Details

Name / Relationship
Phone / Mobile / Email
Please tickany activity or service that you would be interested in participating in:
The Rainbow Program:
Wellbeing Discussion Group
Skills based Workshops
Cooking & Nutrition Group
Social Discussion Group
Walking Group / ☐
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☐
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☐ / Arts & Craft Wellbeing Group
Computer Literacy Group
Monthly outing
Music Group
Friday lunch BBQ / ☐
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☐
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Other MHF services:
Carer’s Respite
Participant Respite
Information and Referral Services / ☐
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☐ / Supported Accommodation Services
Personal Helpers and Mentors Program
Skills and Education Services / ☐
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MEMBER CARE PLAN

List all current Diagnoses:

List signs for staff and fellow members to look for, that may indicate that you are at risk of becoming unwell:

Do you have any allergies or health issues we should be aware of?(Eg. Diabetes, Asthma.)

☐No

☐Yes(If yes, please provide details include medications, medical requirements or anything else we should know in case of emergency)

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CONSENT TO RELEASE INFORMATION

Consent authorising the obtaining and / or release of personal information.

Mental Health Foundation employees will treat your information in a confidential manner however as we work in a team, all members of the team will have access to your information. If you are a client of other Mental Health Foundation ACT (MHF) services we will also share information with these services if this is in the interest of your care and treatment. We also have independent clinical supervision and may discuss aspects of your service provision with our supervisor in order to provide you with the best possible care and treatment. Information will be used to assist in identifying, planning and providing appropriate services to best meet your needs.

You have the right to request to review what information we are keeping on your personal record.

I ______hereby give my permission to any authorised officer of the MHF to release, or seek, confidential information from the following individuals or organisations in the interests of my care and treatment and in accordance with the ACT Health Records (Privacy and Access) Act 1997.

Individual or Organisation / Contact Person / Contact Details
Carer/ Emergency Contact
ACT Mental Health Service
General Practitioner
Psychiatrist
Psychologist
Counsellor
Other MHF Service
Other
Other
Client Name / Signature / Date
Staff Witness name / Signature / Date

MEMBER RIGHTS

All people accessing MHF services as consumers have the following rights;

  1. Respect

To be treated with respect and dignity, as an individual, free of discrimination. To request a staff member of the same or different gender for service delivery.

  1. Safety

To be safe when receiving supports, to expect a high quality of service in the least restrictive environment appropriate to your needs, to receive timely and comprehensive information about your support, and the ability to seek a second opinion about your treatment and care supports.

  1. Communication

To be in a safe environment when exchanging information, to ask questions concerning your care and have them answered, to be provided with full details regarding your options of support and care, and to express your opinions and preferences.

  1. Access

Acquire timely access to support services that promote independence and recovery. To choose if and when family, friends or other supports are included in your care.

  1. Participation

Receive services that support you to live, work and participate in your community and align with your recovery plan. Participate in decisions and choices about your care throughout all stages of your care and recovery. Receive information in a form and language that you understand. Access independent advocacy and legal advice regarding your services, care and social needs.

  1. Privacy

Your personal information remains private and confidential. Records containing this information will be kept secure, and you are able to review your own record upon request.

  1. Comments

You are able to comment on your care and have your concerns addressed. You have the right to provide formal feedback to the organisation via the MHF Feedback and Complaints mechanisms. Feedback and Complaints forms are included in consumer Welcome Packs, can be downloaded from the MHF website or provided on request from any MHF staff member.

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MEMBER RESPONSIBILITIES

All Members, visitors, staff and volunteers at the Rainbow have the following responsibilities;

  • Members are obligated to accept personal responsibility for their actions.
  • Members must follow direction of the Rainbow staff when given.
  • To treat others with respect, dignity and courtesy.
  • To respect other’s religious, moral, cultural, social opinions and beliefs.
  • To share the Rainbow space with other members in a courteous and friendly manner.
  • To respect the rights of members and staff to an environment free from harassment/antagonism. Harassment, threats, threatening behaviour, or physical violence may result in immediate cancellation of membership.
  • To leave immediately if asked to leave by a staff member.
  • If placed on a recovery period, to abide by conditions of any recovery leave plan.
  • Must not be under the influence of alcohol or illegal drugs or bring them onto the premises.
  • Must not solicit or trade at the Rainbow and must not lend/loan or borrow money at the Rainbow.
  • Any person who damages or steals Mental Health Foundation property or goods is responsible for the cost of repair or replacement of property or goods
  • To pay where required for all amenities and services used.
  • To maintain an appropriate level of personal hygiene.
  • To let staff know if a fellow member is becoming unwell or behaving inappropriately.
  • To refrain from sexual or offensive language or behaviour.
  • To use all computers in an appropriate manner, no viewing or downloading offensive, inflammatory or inappropriate material.

I have read or had explained to me all of the listed rights and responsibilities, I fully understand them and agree abide by these rules as a Rainbow member.

Member Name / Signature / Date

Rainbow Membership FormVersion 3.007/01/2016