Request for Release of Personal Information form

Why do we need this information?

To locate and release personal information we need certain details from you. These details confirm that you have the authority to receive the records and they help us search the archives.

What if I do not have all the information?

We understand you may not be able to provide all the information requested. We will try to help you as much as we can with what you give us. The more you can provide the more widely we can search the records.

If you need help to fill in this form please contact the Past Clients and Heritage Services on 03 9429 9266.

Applicant details

(Proof of ID Required for ALL Applicants)

First name

Last name

Phone

Mobile no.

Postal address

Relationship to person in request

Personal information requested

Family name/s

Given name/s

Other names known by

Date of birth

Place of birth

Birth Mother’s name

Birth Father’s name

Adoptive/Foster Parents name/s

When placed (approx year/month)

Where placed (e.g. Unit or address)

Services/s (e.g. Resi, School etc)

Postal address of person

Phone no. of person

Mobile no.

Email address of person

Reason for request

Attachments

To meet Privacy requirements, we ask for documents of identification.

Copies of these documents can be uploaded here, or posted, or scanned and emailed to the following details:

The Heritage Service, Client Information and Support

Berry Street

Level 3, Building 9, 588 Swan Street, Richmond, VIC 3121

Email: Heritage@berrystreet.org.au

If the records are your own:

If the records are your own, please attach:
- copy of your birth certificate OR
- copy of your driver’s licence OR
- copy of your Key Pass OR
- copy of your Passport

If applicable, please attach evidence of any relevant name change/s

If the records are a relative's:

To request information about a relative, please provide signed and dated consent from the former client

To request information about a relative, please provide proof of identity of the former client:
- copy of birth certificate OR
- copy of driver’s licence OR
- copy of Key Pass OR
- copy of Passport

If applicable, please attach evidence of any relevant name change/s

If requesting records for a person who is unable to provide consent:

To request records for a person who is unable to provide consent because of incapacity, please provide evidence of incapacity such as:
- Statutory declaration OR
- Medical certificate

To request records for a person who is unable to provide consent because of incapacity, please provide Proof of your relationship

If requesting records for a person who is no longer living, please provide:

Death certificate

Proof of your relationship

For Aboriginal or Torres Strait Islander people who don’t have documentation listed above

Proof of identity and proof of connection to family members can include an endorsed genogram, Certificate of Aboriginality or confirmation in writing from such groups as Link Up. The Heritages Service will consult with the organisation that produced the documentation.

Upload file

Confirmation

I confirm that: I am seeking information about myself (identification attached above)I am seeking information of another person who is living (contact details to be provided)The person whose information I am seeking is deceased (proof of death and proof of your relationship to that person attached above)

I am a service provider who has consent from the aforementioned client to request and receive a copy of the clients records - please record worker and organisation details under "Applicant details" above

Signature

Type your name to sign/authorise

Date