First Name *

Last Name *

Gender *

Date of birth *

Email Address

Phone number *

Preferred Method of Contact *

Who completed the form? *

Referrer Organization Name *

Referrer Name *

Referrer Phone *

Referrer Email *

Referrer Role *

Support Person Name *

Relationship with the Applicant *

Support Person Phone Number *

Residential Address *

Street address *

City *

State *

Postcode *

Briefly describe your current situation to accessing primary health care services

Please describe your situation

Do you currently receive any health support services on a regular Basis?

Please provide details of your current health support services

Are you from a Culturally and linguistically Diverse(CALD) background?

Have you had a Refugee experience?

Are you currently experiencing homelessness or at risk of homelessness?

Do you reside in any of the areas listed below? *

Bankstown
Campbelltown
Liverpool
Fairfield
Wollondilly
Camden
Wingecarribbee

Preferred language *

Do you require an interpreter?

Preferred Time for Contact

Do you have any specific concerns or requests?

How did you hear about the Health Navigation Support Service?

Please specify *

How would you like to receive the navigator service?

Privacy Information Statement

Settlement Services International Limited ( SSI) is committed to respecting and protecting the privacy and rights of individuals in relation to their personal information.

SSI Group will collect, keep and deal with your personal information in accordance with the requirements of the Service Navigation Support Service ( Service), applicable legislation (including the Privacy Act 1988 and state legislation as may apply) and SSI Group’s Privacy Policy, accessible at https://www.ssi.org.au/privacy/.

SSI’s Privacy Policy sets out how you can access or correct your personal information or make a complaint about a breach of privacy. You may also seek further information or request a copy of the Privacy Policy from SSI Group’s Privacy Officer, at privacy@ssi.org.au. 

Why we need to collect your personal information

The Service collects personal and sensitive information for the purpose of contacting you about the Service, assessing eligibility to access the Service and delivering the Service. We will not disclose your personal information to any other service provider without first seeking consent from you.

Types of personal information we may collect

The types of personal information we will collect about you may include:

your name and contact details  
your cultural and language background, and
your health information.

We will use this information to:

contact you about your Expression of Interest
assess eligibility for the Service
provide services to you
assess and improve our service delivery, and  
evaluate program outcomes and to report on these to funding bodies.

When we might give your information to others

For the above purposes, your information may be given to the funder of the Services, the South Western Sydney Primary Health Network Limited, if requested.

What if you don’t want to give us the requested information, or if you change your mind

We need to collect this personal and sensitive information for the purpose of contacting you about the Service, assessing eligibility to access the Service and delivering the Service. You do not have to provide consent and your decision not to provide consent will in no way affect the Services we provide to you. However, if you do not provide sufficient information in the Expression of Interest, it may mean we are unable to assess eligibility for the Service.

You are free to change or withdraw your consent at any time by following the procedure in the Privacy Policy. Talk to your contact at SSI, who will support you to change or withdraw your consent.

I have read the above information. I understand the reasons for SSI to collect my personal information and the ways in which it may be used and disclosed, and I provide my consent to that collection, use and disclosure. I understand I am free to withdraw consent at any time. *

YesNo

I understand completion of this Expression of Interest does not guarantee acceptance into the Service. Acceptance will be determined based on meeting eligibility requirements and availability of services. *

YesNo

Thank you for your interest. Unfortunately, we are unable to proceed with your expression of interest as we did not receive consent. Please feel free to reach out if you have any questions or need further information.