I, the undersigned, certify that I (or my dependent) understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be treated confidentially by The Snowflake Clinic. I am aware of the limits of confidentiality, including in the event that there is a concern for someone's welfare, information may need to be provided to others in order to keep someone safe. Further details about privacy and confidentiality are available on the The Snowflake Clinic's website at: http://www.snowflakeclinic.com.au/other-information.html . It is my responsibility to inform the Snowflake Clinic of any changes in my personal circumstances.