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DisabilityPlus Consent Form
Complex Care Counselling
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DisabilityPlus Consent Form
DisabilityPlus Consent Form
DisabilityPlus Consent Form
Client Consent Form
Name
*
Last
*
Date of Birth
*
Address (street)
*
Postcode
*
Email
*
Telephone
*
Consent Statement
By signing this form, I agree I have received an Assessment Session with a qualified Therapist undertaken by DisabilityPlus Counselling & Psychotherapy.
The Therapy Session was taken with the sole purpose of gathering information from me to enable DisabilityPlus to submit a Funding Request Document on my behalf.
I understand that the information within the document will be shared with my doctor & subsequently shared with a funding panel to determine my suitability for specialist counselling.
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Consent
Who is giving consent?
Client (Myself)
Carer
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Client Authorisation
If this is not possible due to disability please ask your carer to sign in the section below.
Date
Signature
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Authorised Carer Authorisation
Only to be completed if the client cannot write a signature.
Carer Name
Carer Relationship to Client?
Date
Signature
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If you are human, leave this field blank.
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