Name

Email Address

Phone Number

Date

All clinical information shared with my therapist will remain confidential within their service except where they believe there may be a risk of harm to myself or others, or where there’s a legal duty of disclosure. All clinical information shared with my therapist will remain confidential within their service except where they believe there may be a risk of harm to myself or others, or where there’s a legal duty of disclosure. I understand

My therapist has case supervision with their supervisor where a broad outline of my case may be discussed as a part of the supervisory process and that no identifying details will be revealed. My therapist has case supervision with their supervisor where a broad outline of my case may be discussed as a part of the supervisory process and that no identifying details will be revealed. I understand

I have read and understood the HGI Information for Clients sheet, including the section about use of questionnaires and how the data will be used in service evaluation and research, and I understand that by ticking the box below I am giving permission for my anonymised data to be used for service evaluation and research and that I can withdraw my consent to this at any time by contacting my therapist. I have read and understood the HGI Information for Clients sheet, including the section about use of questionnaires and how the data will be used in service evaluation and research, and I understand that by ticking the box below I am giving permission for my anonymised data to be used for service evaluation and research and that I can withdraw my consent to this at any time by contacting my therapist. Yes

My personal information will be kept in accordance with the Data Protection legislation. By ticking the box opposite, I consent to information about me being held by the therapist, which means that they will: My personal information will be kept in accordance with the Data Protection legislation. By ticking the box opposite, I consent to information about me being held by the therapist, which means that they will: Use my contact details only to get in touch with me about matters relating to my treatment, such as appointments and to provide helpful information, where appropriate. Not share my personal information with other individuals or organisations, except where they have reason to believe that I or others to be at risk of harm, or where there is a legal duty to disclose it Retain a record of my treatment for a period of 7 years, in accordance with professional requirements and will take steps to ensure the accuracy and security of the record. Provide me with access to the information they hold about me, if I request it.