This Form Provides Details on Consent to Share Personal Information About
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Family Partnership Zone Information sharing consent
This form provides details on consent to share personal information about: Parent /Carer Forenames Surname Date of Birth
Parent /Carer Forenames Surname Date of Birth
Child / Young Person Forenames Surnames Date of Birth
Child / Young Person Forenames Surnames Date of Birth
Child / Young Person Forenames Surnames Date of Birth
Child / Young Person Forenames Surnames Date of Birth
Other household members (if applicable) Forenames Surnames Date of Birth
1 Family Partnership Zone
Family address (including postcode): Telephone numbers:
National Impact Study From time to time we are also asked by the Department for Communities and Local Government or their appointed representatives (currently the Office for National Statistics) - to provide information that we hold for the purposes of research into the effectiveness of this programme and the difference we are making for families. Information sharing agreements are in place to ensure that the information can only be used for carrying out research. It cannot be used to make decisions about Individuals. It will be impossible for any person or family to be identified from any published reports.
The use of Data – To be explained by the worker completing this form with you The worker who is completing this form with you should explain the following: Why the information is needed, what will be shared and with who, how long it will be stored and how long, what happens if you don’t give consent to share, your right to withdraw or restrict consent at any time, your rights under the Data Protection Act, the complaints procedure, who to contact for further information. Please ask if you do not understand or are unsure about any of these things.
2 Family Partnership Zone I agree that you can ask for information about me and share information with;
GP, health visitor, school nurse or primary care/community health professional Hospital for physical and or mental health care Community, Child and Adolescent Mental Health Teams Prison and Probation services Housing Associations Police Job Centre Plus Adult and Community services – including substance use services Children’s Services including the youth offending team, social services District/Borough Councils Schools, Colleges and other educational establishments
Please note any exclusions and identify which family members this applies to:
Consent I confirm that I have been told about of the information sharing agreements, I consent to this and I understand that I have the right to withdraw or restrict consent at any time.
(Note to Worker : Please ensure all member s of the family over the age of 16 are asked to sign the form. Parents may sign for any children under the age of 16).
Parent/ Child/ Signature Date Print name Carer young person
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