This information may include:

• Where you live, and information about you, such as your date of birth • • information about your disability • • your NDIS plan or funded supports • • medical and therapist reports • • other information that will assist Marley Ability in providing you Support Coordination •

If you agree to Marley sharing and receiving information about you from third parties, please fill in and sign the form on the next page.

Marley Ability will share this form with third parties to show them you have agreed for Marley Ability to talk to them about you and exchange information about you, if requested. If you do not want this to happen, you do not have to give your permission. If you decide you do not want Marley Ability to have permission anymore, you can withdraw your consent by contacting us. However, if Marley Ability does not have all the information it needs, the following things may happen: • Support Coordination Support may be ineffective and may take longer to coordinate and engage you with services • • You will need to be the intermediary contact between services and us as the support coordination to pass on the required information to either party, this may result in depletion of funds. • • If you do not permit Marley Ability to ask a third party about you, we will ask you for your information instead. • • There are certain circumstances where Marley Ability may also be required or allowed by law to talk to other people about you; give them your information or ask for information about you without your consent. •
If Yes, please fill out the details below.
If yes, please state which Language above.

Parent, legal guardian or representative

Fill out this section if you are completing this form on behalf of: • a person under 18 years for whom you have parental responsibility, or • a person for whom you are a legal guardian or representative. We may ask you to provide confirmation that you are authorised to represent the participant and to verify your identity.
(You would edit this to fit your needs). Outline study duration, the purpose of the study, the study procedure, and highlight the fact the individual is voluntary participant. "I know that my participation is voluntary and that I can choose to withdraw from the research at any point."
Please write below the included people you want to share your information with.
Please leave this blank if there's no one you would like to include. This can be changed / modified or updated at any time.

Third party details & consent for NDIA Communication

I consent to the NDIA giving information about me (or the participant I am representing who is identified in this form), to Marley Ability (ABN: 85 107 236 231)
Please mark the relevant boxes above to indicate the information you give the NDIA consent to share with Marley Ability.
Please mark the relevant boxes above to indicate the information you give the NDIA consent to share with Marley Ability.
Please mark the relevant boxes below to indicate the purpose of your consent for us to share this information. If you are unsure, you can leave it as the default, for Support Coordination purposes/review.
Please Click All Of the Above, to show that you understand and agree to all of these consent items. If you have any questions, please contact us and we will help you as soon as possible.
Or Participant Name if Verbal Consent