Toggle navigation
Home
DisabilityPlus Consent Form
Complex Care Counselling
Home
/
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.
Section Buttons
Consent
Who is giving consent?
Client (Myself)
Carer
Section Buttons
Client Authorisation
If this is not possible due to disability please ask your carer to sign in the section below.
Date
Signature
Section Buttons
Authorised Carer Authorisation
Only to be completed if the client cannot write a signature.
Carer Name
Carer Relationship to Client?
Date
Signature
Section Buttons
If you are human, leave this field blank.
Submit