Consent form

Consent Form 1st August 2023 – 30th September 2024

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.

Student name: *
Student ID number/Exeter reference number: *
Date of birth (e.g. 20/09/1988): *
Email:
Mobile number:

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').
I give my consent: *

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').

I give my consent: *

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.
Local NHS mental health/health and social care staff (STEP, crisis team, Liaison Psychiatry) *
GP Surgery/Doctor (please give Surgery/Doctor's name and address below if not the Student Health Centre) *
GP Surgery name and address
Parent/Emergency contact (please give contact details below) *
Parent/Emergency contact information - please specify their name, relationship to you and all contact details (mobile, home telephone, email address)
Trusted Contact (A trusted contact is usually a parent, carer, guardian or family member. Students should ensure that their trusted contact is aware they have been nominated for this purpose and that their contact details have been given to the University).
Trusted contact information - please specify their name, relationship to you and all contact details (mobile, home telephone, email address)
Disabled Students’ Allowances (DSA) Access Centre & assessor *
Student Finance / DSA funding body *
Third Party Accommodation Providers e.g. Unite, UPP

External Consent - Student Health Centre and NHS University Mental Health Team
Students' Guild
Other e.g. external NMH provider (such as Randstad)
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.
Student Health Centre (SHC) - for details of their privacy policy, please see here: https://www.exeterstudenthealthcentre.co.uk/privacy-statement/ *
Local NHS University Community Mental Health Team - for details of their privacy policy, please see here: https://www.dpt.nhs.uk/legals/privacy *
If there are other requirements that you wish us to consider between organisations, then please indicate here and these will be considered:
I confirm that I have read the document ‘Consent Agreement’, and that the above information is correct to the best of my knowledge. I will inform Wellbeing Services of any change in my circumstances. I consent to my information being shared as outlined above. *

An electronic consent form can be completed online.

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

This form is harvested into SID and is then uploaded by the administrative team to a student’s case file under the folder ‘consent’. Each ‘consent’ folder should be labelled for the academic year it was completed.
A paper copy of the consent form is found on the N drive if the student is unable to complete the online form. If a paper form is completed, this should be uploaded to the student’s SID case record as a priority and a brief note added to a ‘consent’ folder to indicate to practitioners that they can find the form on files.

The service recognises that, in some instances, it may not be possible or appropriate for a form to be completed. Consent given verbally should, however, be noted in the Consent folder. If possible, an email should be sent to the student following the conversation to confirm the consent given, and a form completed at the earliest opportunity.

Ideally, consent (whether online or paper forms) is reviewed annually, and a new form completed each academic year. This can be challenging given the scope of services a student may be supported by. It is best practice for all practitioners to review at their first meeting with a student whether consent has already been completed within the academic year of contact. This may not be possible for practitioners undertaking Drop-In Appointments, WBC or ILP appointments. If a student has capacity and declines permission to liaise with external agencies and/or their parent/emergency contact then their wishes will be respected (unless ‘exceptional circumstances’) in line with our service ethos, data protection policy and confidentiality statement. This should be documented in a ‘consent’ folder and a note written to reflect the discussion and the outcome of this discussion (i.e. was consent agreed?).

Students can withdraw or change their consent at any point and should be directed to complete a new consent form or email wellbeing@exeter.ac.uk. If a practitioner sees a student who has a consent form in place, it is good practice to review the current consent folder and to confirm that these details remain up to date.