Consent to Disclose Form

Consent to Disclose

By filling out this form you are allowing Bridge Housing to contact the nominated people about your tenancy under the conditions described below.

I,

of

Give Permission - Contact

give my permission for the staff of Bridge Housing to contact the following people:

Name

Organisation / Relationshiprelationship to you

Phone

Email

Give Permission - Referrals

give my permission for Bridge Housing staff to make referrals to the following organisations or services

Revoke Permission

revoke permission for Bridge Housing staff to contact the following people

Under The Following Conditions

Under the following conditions:

In connection with my tenancy
When I cannot be reached by phone and it is urgent that I am contacted for reasons to do with my tenancy
When I have been contacted but staff are concerned about my response and have let me know this
When staff are concerned about a breach of my tenancy agreement and the above person/people may be able to help me stop the problem getting worse
When action has been taken or is likely to be taken to terminate my tenancy and the above person/people may be able to help me keep my home
Any other reasons - please list below:

I understand that only matters relevant to sorting out the immediate problem will be discussed when I am not present.

I understand that I can withdraw my permission at any time by selecting 'I revoke permission for Bridge Housing staff to contact the following people' above.

Your Signature

Clear

Trustee and Guardian Signature

Clear

Signature

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Date Signed

To continue, type the characters you see in the picture. *

Bridge Housing's Privacy Policy describes how personal information about you is collected, stored, shared to external parties and discarded in accordance with the NSW Privacy Act 1998.