CHAT Tool - Offender Health Research Network

Consent for Information Sharing
I understand that information may be requested from outside agencies in order to ensure that the assessment of
my health is accurate and comprehensive.
I understand that in order to gain appropriate information from outside agencies, it may be necessary to share
information about my current health issues.
I understand that wherever possible, permission will be sought from me to approach outside agencies for
information but where delays may compromise my health, staff may approach outside agencies without my
permission.
Name:
Signature:
Date:
Consent for Parent/Guardian/Person holding parental responsibility Involvement
I understand that information may be requested from my parents/carers in order to ensure that the assessment
of my health is accurate and as comprehensive as possible.
I understand that my parents/carers will be informed of my current health care issues in order to support my
care.
Young person’s name:
Young person’s signature:
Date:
If consent is refused for assessment, information sharing or parental involvement state that consent was declined
and outline the reasons here:
Surname:
DOB:
Forenames:
NHS Number:
CHAT Tool Secure Estate (Version 3 - June 2013)
3 | P age