Complete a Therapy Consent Form

“*” indicates required fields

Please complete this short form to provide Streetwise with the necessary consent to support your participation in any Streetwise activities:

Streetwise sometimes needs to share personal and sensitive information (e.g. name, date of birth, postcode) with other organisations who fund our work. We will only share this information with reputable organisations and when it is necessary to do so. I agree that Streetwise can share relevant information about my child with reputable organisations as outlined above.

Details of young person

Name*

Date of Birth*

Gender*

Gender – if not listed above

Address*

Street Address Address Line 2 City County Post Code

Email Address (by providing an email address you consent to us contacting you by email)*

Phone Number (by providing a phone number you consent to us contacting you by text or phone call)

As part of its work, Streetwise needs to collect and store sensitive personal information about you. In order to do so, the law on data protection requires Streetwise to receive your explicit consent. Explicit Consent: I hereby consent to Streetwise collecting and storing sensitive personal information about me/my dependant concerning the support, advice and / or counselling that I/ my dependent receives when I/ my dependent accesses Streetwise’s services. The sensitive personal information that Streetwise will collect and store will include; name, date of birth, address, residential, marital, ethnicity, medical details concerning my mental and physical health, and emotional wellbeing. I understand that any sensitive personal information collected and stored by Streetwise will: • Be retained for a minimum of eight (8) years after support / counselling has ceased • Be processed in accordance with the 2023 Privacy Notice, which I have read and understood. By signing this consent form, I confirm and understand that: • Confidentiality has been explained to me and I agree that my/ my dependant’s sensitive personal information can be shared with others where another person or my dependant is at risk of significant harm • Sensitive personal information about me/ my dependant can be collected and stored securely by Streetwise, and I understand that such information can be seen by other workers within Streetwise. • With my prior explicit consent, my dependant’s sensitive personal information can be shared with others outside of Streetwise • I will contact Streetwise if I/ my dependant cannot make an appointment that has been made for them • If referred by someone else, Streetwise may inform the referrer when counselling and / or support comes to an end • My/ my dependants’ rights at Streetwise, include how to make a complaint and what rights I/ they have in relation to their sensitive personal information, have been explained to me. • I may request to withdraw my consent to Streetwise collecting and processing my dependant’s sensitive personal data at any time I have read and understood the above and give my explicit consent to Streetwise collecting and storing mine and/or my (dependants) sensitive personal information in accordance with the 2023 Privacy Notice:*

Storing Personal/sensitive information

Sharing personal/sensitive information

I have read and understand the above and give my explicit consent to Streetwise collecting and storing my sensitive personal information in accordance with the 2023 Privacy Notice. Insert Young person’s name below, or if acting as legal guardian, please state your name, role and authority.*

Worker’s name

I give permission to receive emails from Streetwise, including via electronic email distribution channels

We may take photos and use recording devices e.g. video cameras for use of display, publicity and project evaluation. These may be passed on to partner organisations during joint events etc. I agree for my child to be in photos and recorded material, to be used for displays, publicity and evaluation reasons. I also agree for photos and recorded material to be shared for publicity and promotional use.

Complete a Therapy Consent Form

Details of young person

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