Consent form - Penryn Welfare team - September 2023 to 31 August 2024

Please complete this form if you have either attended a meeting with the welfare team or have a meeting upcoming. Permission to share information enables us to link you in with appropriate support for your studies and to provide effective help with your wellbeing and welfare. Please complete all sections. Should you wish to amend or withdraw your consent at any point you can do so by emailing welfare.penryn@exeter.ac.uk – this may impact the level of support we are able to offer.

More information

Part 1) FXplus
The Education welfare team in Penryn are part of Wellbeing services for Exeter University and we respect your rights to privacy as outlined in the confidentiality statement (see link above). As we are based on the Penryn campus we work alongside Student Services which are provided by Fxplus. Information on their data sharing policies (see link above). Given the above, in order to provide an effective and safe service to you, we will share information from meetings and communications with you with members of staff from the Wellbeing and Living Support teams in FXplus. You may withdraw your consent to this at any point by contacting welfare.penryn@exeter.ac.uk but please be aware that it may significantly limit the level of support that we are able to provide.
Student name
Student ID number
Date of birth
Mobile telephone number

2) Consent within the University
At a meeting with you we will discuss the need to share information on a need to know basis with key University Colleagues/Departments. Examples could be confirming you have engaged with us for mitigation, liaising with the Student records team about registration for you, queries on your behalf with the Education Support team or letting staff know that you may want some extra support to catch up on missed sessions.
I give my consent for information to be released and liaison to take place between the welfare team and other University colleagues/departments on a need to know basis.

2) Consent within the University

At a meeting with you we will discuss the need to share information on a need to know basis with key University Colleagues/Departments. Examples could be confirming you have engaged with us for mitigation, liaising with the Student records team about registration for you, queries on your behalf with the Education Support team or letting staff know that you may want some extra support to catch up on missed sessions.

I give my consent for information to be released and liaison to take place between the welfare team and other University colleagues/departments on a need to know basis.

3) Consent to contact Parent/Emergency contact
Please indicate if you wish to give your consent to share information with your parents/emergency contact
If yes, please specify their name, relationship to you and all contact details (mobile, home telephone, email address)

4) External agencies/Individuals
It may be the case that you are engaged with an external service or agency and that it would be beneficial for liaison to take place between the Welfare team and them. Please indicate below if you are engaged with any of these services and wish for liaison to be permissible. If you are not engaged with a service please select ‘Not applicable’ from the drop down.
GP surgery (please give surgery name and address below)
Surgery name address (if applicable)
Local NHS mental health/health and social care staff (E.G. CMHT, Eating Disorder team, Crisis team)
Services linked in with if applicable.
If there are other requirements that you wish us to consider between organisations, then please indicate here and these will be considered:

5) Exceptional Circumstances clause
Wherever possible staff will seek to obtain your agreement prior to liaison, however it is acknowledged that there may be some circumstances where this is not possible. There may be rare instances when Wellbeing Services are unable to maintain our commitment to confidentiality. In such circumstances we may need to contact relevant others such as your GP or other health professionals. Exceptions to confidentiality occur when Wellbeing Services believe you or others may be at risk of serious harm, when there are safeguarding concerns, and/or when a member of the team would be liable to civil or criminal court procedures if relevant information had not been disclosed. In certain exceptional circumstances (such as where there is an immediate and serious threat to your personal safety or to the safety of others), we may disclose information to your parents/emergency contact or engage with them if we consider this essential for your safety.

5) Exceptional Circumstances clause

Wherever possible staff will seek to obtain your agreement prior to liaison, however it is acknowledged that there may be some circumstances where this is not possible. There may be rare instances when Wellbeing Services are unable to maintain our commitment to confidentiality. In such circumstances we may need to contact relevant others such as your GP or other health professionals. Exceptions to confidentiality occur when Wellbeing Services believe you or others may be at risk of serious harm, when there are safeguarding concerns, and/or when a member of the team would be liable to civil or criminal court procedures if relevant information had not been disclosed. In certain exceptional circumstances (such as where there is an immediate and serious threat to your personal safety or to the safety of others), we may disclose information to your parents/emergency contact or engage with them if we consider this essential for your safety.

6) Submit form
I confirm that the above information is correct to the best of my knowledge. I will inform the welfare team of any change in my circumstances. I consent to my information being shared as outlined above.

Consent to liaise form

Consent form - Penryn Welfare team - September 2023 to 31 August 2024