Information Sharing Consent Form

I hereby give my permission for Children in Mind Psychiatric Psychological Therapy and Treatment Service to share personal and medical information with other service providers in connection with your care and treatment. I agree to a referral being made if necessary to local services to support you. This will be discussed with you prior to any referrals being made.

I understand that Children in Mind Psychiatric Psychological Therapy and Treatment Service may hold information gathered about you from the various services and as such my rights under the Data Protection Act will not be affected. We routinely review your consent to information sharing which can also be reviewed upon your request. You can withdraw consent at any point.

Statement of Consent:

• I understand that personal information is held about me.
• I have had the opportunity to discuss the implications of sharing or not sharing information about me.
• I agree that personal information about me may be shared and gathered from the following agencies:
  • NHS and other Health Services, including my GP practice
  • Early Intervention Service including the police
  • Mental Health Services
  • Education Support Services
  • Social Care
  • Voluntary Sector Organisations