Client Consent Form Client Consent Form Updates Personal Details First NameLast NameContacting you by postAddressAddress Line 1Address Line 2CityPost CodeCan we contact you by post?YESNOContacting you by phoneHome Phone NumberCan we leave a voicemail on this number?YESNOCan we text you on this number?YESNOMobile Phone NumberCan we leave a voicemail on this number?YESNOCan we text you on this number?YESNOWork/Other Phone NumberCan we leave a voicemail on this number?YESNOCan we text you on this number?YESNOContacting you by emailEmail addressCan we contact you by email?YESNOConsent to use your personal informationPermission to record and use your personal information: To help with your enquiry we may need to record details of your case. We must ask for permission to record and use your personal information in this way. All information you share with us is confidential unless we have a concern about the safety of you or the person you care for.I agree to Bromley Mencap recording information about me and understand that this will be confidential unless there is a safeguarding concern. YESPermission to share information for quality checking and collecting feedback: We want to make sure the service you receive meets your needs. To help us understand this and to improve our service, Bromley Mencap may want to contact you later to ask for your feedback. Our services operate within a strict quality framework and may on occasion need to allow an Advice Quality Standard assessor to inspect your casefile to ensure you are receiving the best quality service.I agree to Bromley Mencap contacting me if required to give feedback about the service I received and ensure best quality of service. YESNOConsent to share information for referrals: Everything you tell us will be treated confidentially. Sometimes we may suggest that we refer you to another organisation for advice because they will be better able to help you with all or part of your issue. We can help get you an appointment and give the organisation the information you have already provided so you don’t have to repeat yourself. We will consult with you prior to any sharing of information unless there is a safeguarding concern.I agree to Bromley Mencap sharing my personal information with other advice providers for efficient appointments and referrals to help me with my issues.YESNOConsent to hold information on our database in case you return to us for further support: Once we have supported you, we record the support we have given and copies of any forms that you have asked us to complete with you. If in the future you return to us, it is helpful to have access to these records so that we don’t need to ask you the same questions again.I agree to Bromley Mencap retaining my information to provide further support.YESSubmit Form