Children and young people’s NHS Continuing Care
Consent Form
CP3 – V2.0 November 2017
NAME …………………………………………D.O.B………………………. NHS NUMBER……………………….……….
Children and young people’s NHS Continuing Care
Consent Form
CP3 – V2.0 November 2017
NHS Coastal West Sussex Clinical Commissioning Group, NHS Horsham and Mid Sussex Clinical
Commissioning Group and NHS Crawley Clinical Commissioning Group
NAME ………………………………… D.O.B…………………………. NHS NUMBER………………………
Children’s and Young People NHS Continuing Care
Consent Form CP3 – V2.0 November 2017
Assessment for Children’s NHS funded Continuing Care is a multi-disciplinary process, led by a nominated health assessor, that includes collecting personal and medical information from parents, carers, professionals, files and records. Consent of the parent or the person with parental responsibility for the child/young person is required.
Details of child or young person being assessedSurname / family name: / First names:
Date of birth: / NHS number:
Address & Post Code:
Consent
I am (name):
I am acting with parental responsibility for:
My relationship to the child/young person is:
Consent to share and protect your personal information
Please Tick (ü) as AppropriateI agree that the information provided in this assessment may be shared with Health and Social Care staff and Service Providers who contribute to the care of the child/young person in relation to Children’s NHS funded Continuing Care.
I understand that this information will be used in the assessment of the eligibility of the child/young person for Children’s NHS funded Continuing Care funding.
I understand that I may withdraw my consent to share information at any time.
Data Protection Act: This information is strictly confidential and for use by those agencies involved in the care of the person. This is intended for the individual and/or organisation to which it is addressed and may contain information that is privileged and confidential. If you are not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication and its attachments is strictly prohibited. Mental Capacity Act (MCA 2005)
Name:
Signature:
Address:
(if different from the above)
Phone Number:
(if different from the above)
Accessible Information
(If not completed as part of referral or assessment)
Does the patient/representative have a disability, impairment or Learning Disability that requires an alternative communication format? / Yes / No
(Please delete as appropriate)
If yes please advise who requires the alternative communication format:
If yes please select the reason for an alternative communication format
d/Deaf / Hearing impairment / loss
Blind / Sight impairment / loss
Deafblind / Disability
Other (Please provide details)
If yes please select the preferred alternative communication format
Large Print / Easy Read
Braille / British Sign Language
Audio Format / Email / Electronic Format
Other (Please provide details)
Does the patient/representative have a problem with understanding or speaking English? / Yes / No
(Please delete as appropriate)
If yes please advise who requires the alternative communication format:
If yes please advise CC what their preferred language is:
Patient’s Name: / Signature:
Patient’s Date of Birth: / Date:
CHC correspondence can be requested in LARGE PRINT or alternative accessible information formats by calling 01903 708 609.
NHS Coastal West Sussex Clinical Commissioning Group, NHS Horsham and Mid Sussex Clinical
Commissioning Group and NHS Crawley Clinical Commissioning Group
NAME ………………………………… D.O.B…………………………. NHS NUMBER………………………