Appendix 03 – Form 02

Children and Young People Service (CYPS)

Consent Form

Patients Surname (Family Name)
Patients First Name(s)
Date of Birth
Responsible Health Professional
Job Title
NHS Number / RiO Number
Male / Female
Patients Parent(s) Name(s)
Parental Responsibility
Special Requirements
(e.g. other language/other communication method)
To be retained in patient’s notes

Sharing and gathering information about you

As part of your assessment and treatment we gather information from other services, agencies and in combination with what you tell us about yourself, as this helps us to get a clear picture of your history and current needs, as well as any risk of harm to yourself or others.

The information gathering process will only relate to records that are relevant to your assessment and with the information you give us will be kept in your Health Record (written and computerised) to help us to provide you with the most appropriate care.

We have a duty to keep information about you private and confidential. However, in certain circumstances, there may be occasions where it is necessary to share information without your consent to protect you, or someone else, from harm. In these circumstances we will tell you that we are going to share information, what that information is and who we will share it with.

Do you consent to us seeking and sharing information as part of your assessment and treatment?
Yes / No
Are there any people you do not want us to contact?
Yes / No
Name(s) / Address / Relationship
Who else would you like us to share with or gather information from?
Name(s) / Address / Relationship

As part of your assessment and treatment we may write letters about your care. We would like to give you a copy of these letters. We believe it would help you to understand and make choices about your own health care and treatment. However, we realise that everyone will want to have a copy and it is your right to choose if you wold like to receive a copy.

Do you want to receive copies of letters? / Yes / No
Would you like your parent/carer to receive copies of letters? / Yes / No
How would you like to receive copies of letters?
Home Address: / Another Address:
(Please state)
Other:
Do you have any specific requirements to read the letter?
Large print / Braille / Other language / Other:
We would like to support you to attend all your appointments with us
Would you liketo receive notification of appointments by:
Please insert Mobile Number or Email address in box below if appropriate
Text message / Yes / No
E Mail / Yes / No
Would you like to receive a text message to remind you to take any prescribed medication? / Yes / No
We may ask you in the future if you are interested in taking part in relevant research studies –
Would you be interested in taking part? / Yes / No
You can change your mind at any time about any of the above; please let your responsible health professional know
Name(print / Signature / Date
Name(print) / Signature / Date
(Parent/carer on behalf of young person)
Name(print) / Signature / Date
(Responsible health professional)
Job Title

Consent to Treatment

Your responsible health professional will explain to you the nature and purpose of any intervention and treatment, including the benefits and any significant, unavoidable or frequently occurring risks.

Your responsible health professional may recommend changes to the Plan as the intervention or treatment progresses and will always keep you informed of the intentions and side effects of any new or changed treatment.

This form is for your responsible health professional to confirm that you have had the proposed treatment explained to you, that you have understood it and that you agree to the treatment.

In future your consent to any significant changes to the Plan will be confirmed on a similar form or documented in your Health Record.

Name of intervention / course of treatment agreed:

Statement of health professional (to be filled in by health professional with appropriate knowledge of the proposed intervention/treatment plan as specified in the Consent Policy

I ………………………………….. have explained to ……………………………..the intervention/treatment plan proposed, including any medication to be used and the benefits, risks and side effects of such. This includes any available alternative treatments (including no treatment) and any particular concerns of those involved.

The following leaflet/tape/web link has been provided:
The medication is
Licensed / Unlicensed / Prescribed off label
Statement of interpreter (where appropriate)
I have interpreted the information to the patient/parent/carer to the best of my ability and in a way which I believe she/he/they can understand
Print Name / Signature / Date
Statement of patient/parent/carer
I agree to the intervention/treatment plan descried above. I understand that if intervention/treatment changes at any time the appropriate responsible health professional will seek new consent
Print Name / Signature / Date
Relationship to Patient
Confirmation of Consent
I have confirmed that the patient/parent/carer has no further questions and wishes to intervention/treatment to go ahead
Print Name / Signature / Date
Job Title

Northumberland, Tyne and Wear NHS Foundation Trust1

Appendix 3– Form 02 -CYPS–Consent Form–V04.4 – Iss 2 – Sep 17

Part of NTW(C)05 – Consent to Treatment and Examination Policy