ACAC CCM 020 Service Refusal Risk Acknowledgement V2.0

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Client Details

Who this form relates to.

Client Full Name *

Date of Birth

This form is being completed by: *

👤 The client themselves 👥 A representative on behalf of client

Representative Name

Relationship to Client

Representative Phone

ACAC Staff *

Job Title

🧠

Capacity & Decision-Making

Confirm the client's ability to make informed decisions.

Client has been deemed capable of making responsible decisions?

Yes No

Client has a medical or psychiatric diagnosis that may impair decision-making?

Yes No

Diagnosis

Client's emotional state at time of decision

😌 Calm 😟 Distressed Other

Describe emotional state

Client's Medical Practitioner has been informed?

Yes No N/A

The Adult Guardian has been involved in the decision-making?

Yes No N/A

⚠️

Activity, Service Refusal & Risk

What is the client refusing or choosing to do, and what are the risks?

Type of refusal or risk *

🚫 Refusal of a service

⚠️ Risky activity / behaviour

💊 Medication related

🏥 Medical treatment

🚶 Mobility / falls risk

🏠 Living arrangement

📋 Activity / Service Refusal / Behaviour Identified

Describe the activity, service refused, or behaviour * Staff, management and/or Doctor / Allied Health Professional discussed the risks of the following:

Anticipated risks identified * Note: there may be additional or different risks beyond those listed. The client takes responsibility for all associated risks.

✅

Client Acknowledgements

The client confirms they understand and accept the risks.

I, the client, hereby acknowledge that:

The risk of the above activities was discussed with me, and it was fully explained by ACAC staff and management. I will take full responsibility for the risk associated with the above planned activity or behaviour.
I will ensure I consider my own safety when I partake in the planned activity or behaviour.
I understand and have actively participated in the risk assessment process.

✍️

Sign-off

Select the signing method that applies.

How will this be acknowledged?

Client Signature

Client draws signature below * Use finger on touchscreen or mouse on desktop

✏️ Draw signature above

Date

— OR — Representative (legal appointment)

Representative Signature (if applicable)

Name

Relationship

Signature

🖊 Click to sign

Date

ACAC Representative Signature

Name & Position

Date

Signature

🖊 Click to sign

Signed copy provided to client?

Yes Not yet

☐ I have discussed the purpose of this acknowledgement and the activities/behaviours that the client is choosing to partake in, and I am satisfied that the client identified above understands the associated risk, and has provided their informed verbal acknowledgement.

Employee Signature (verbal acknowledgement)

Employee Name

Job Title

Signature

🖊 Click to sign

Date

Verbal acknowledgement provided by client?

Yes No

Signed copy provided to client?

Yes No

☐ I have discussed the purpose of this acknowledgement and the activities/behaviours that the client is choosing to partake in, and whilst I am satisfied that the client has had the associated risks discussed with them, they are exercising their right not to sign or provide a verbal acknowledgement.

Employee Signature (refused to sign)

Employee Name

Date

Signature

🖊 Click to sign

Signed copy provided to client?

Yes No Client refused copy

Office Use Only

VC review note entered

Date of next review Minimum: 12 months from today

⚠️ Data handling reminder

Privacy Act 1988 & Aged Care Act 2024. Save directly to Visual Care only. Provide signed copy to client. Do not email or share outside ACAC systems.