DisabilityPlus Consent Form

Client Consent Form

Name

Last

Address (street)

Postcode

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.

Consent

Who is giving consent?

Client (Myself)

Carer

Client Authorisation

If this is not possible due to disability please ask your carer to sign in the section below.

Date

Signature

Clear

Authorised Carer Authorisation

Only to be completed if the client cannot write a signature.

Carer Name

Carer Relationship to Client?

Date

Signature

Clear