Information Sharing Consent Form

This form can be used if a CAF has not yet been completed, however as the CAF form includes a ‘Consent statement for information storage and information sharing’, it is not needed when a CAF is completed.

Child/Young person

Name …………………………………………………………………..…………….

Address ………………………………………………………………......

Post code …………………… Date of Birth …………………………..

  • I understand that personal information is held about me/my child.
  • I have been given a copy of the leaflet on ‘Confidentiality and Sharing Information for Families in Oxfordshire’.
  • I have had the opportunity to discuss the implications of sharing or not sharing information about me and my child/children.
  • Personal information is made up of basic and additional information. Basic information means name, address, gender, date of birth, school attended, GP, parents or primary carer.

I agree that basic personal information about me/my child may be shared with the following agencies – please add any others which may be relevant

Please tick as appropriate / Please tick as appropriate
Early Intervention Service / Primary Child and Adolescent Mental Health Services (PCAMHS)
Children and Adolescent Mental Health Service (CAMHS) / Police
Children’s Centres / Schools and Colleges
Information Advice Guidance Service / Social Care
Early Years Settings / Voluntary Sector Organisations
Education Support Services / Health Services
Educational Psychology Service / Other Services:
Adult Services

Additional information includes any identified needs you/your child may have and how they may be met. It may include relevant sensitive information such as ethnic origin, religion, mental health, sexual health, offences alleged or committed.

Are there any agencies you do not want us to share additional information with? Please list them here:

______

I agree to my/my child’s basic information being shared between services

I agree to my/my child’s ‘additional’ information being shared between services

I do not agree to my/my child’s additional information being shared. I understand that this may make it more difficult to get the help needed.

Signature of parent ……………………………………………………………….

Print name ………………………………………………………………………….

Date ………………………

Signature of young person ……………………………………………………..

Print name ………………………………………………………………………….

Date ………………………

Signature of professional ……………………………………………………….

Print name ………………………………………………………………………….

Agency/ service …………………………………………………………………...

Please note:For children below the age of 12 the decision about sharing information will generally be the responsibility of the person with Parental Responsibility. The general concept is that young people aged 12 or over may give or withdraw consent if they are deemed to understand the process. At the age of 16, most young people are deemed to be able to understand the implications of giving consent (those with significant learning difficulties may be the exception) and are therefore able give and withdraw consent individually

The leaflet ‘A guide to confidentiality and sharing information in Oxfordshire’ can be found on the Oxfordshire Early Intervention Service website

February 2012 Oxfordshire Early Intervention Service v2