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Consent form

Consent Form 1st August 2021 – 30th September 2022

Please only complete this form if you have been advised so by a member of staff in Wellbeing Services. Please ensure you complete all sections by selecting ‘Yes’, ‘No’ or ‘Not Applicable’.

If you have an Individual Learning Plan (ILP) in place, you will have already given your consent for information to be shared on a need to know basis with other university departments and therefore will need to tick the box under the section ‘Within the University’ to ensure this continues.

Before completing this form, please ensure you read the following with regards to how your information will be shared - Consent Agreement.

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Consent within the University
I give my consent for information to be released and liaison to take place between Wellbeing Services staff and other University colleagues/departments, including the University Sports Park, INTO UoE and Estate Patrol on a ‘need to know’ basis. (If you have completed a health and disability declaration form you have already given consent for internal University liaison for the duration of your course. Therefore please select 'Yes').
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External Consent - other agencies/individuals
I give my consent for information to be released and liaison to take place between Wellbeing Services staff and the people or services ticked below. Please tick all that apply and give names as appropriate.
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External Consent - Student Health Centre and NHS University Mental Health Team
In order to ensure students are supported effectively and to enable the University to be responsive to your health needs, Wellbeing Service staff routinely communicate with NHS services including the Student Health Centre and University Community Mental Health Team (U-CMHT). If you give your consent for liaison with the Student Health Centre and U-CMHT below, then please be aware we will forward this section of your consent form to both of the above mentioned teams as evidence of your explicit written permission for liaison and sharing of information between these services on a ‘need to know’ basis. Please see each service's privacy policy for details of how your data is used and stored.
I give my consent for information to be released and liaison to take place between Wellbeing Services staff and the services ticked below. I am aware that if I consent this section of the form will be forwarded to the Student Health Centre and U-CMHT for their records. Please tick all that apply.
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