Contact and Consent Form

Havering SENDIASS provide a free, impartial and confidential information, advice and support service offering assistance to parents/carers of children with SEND aged 0-16 years and young people themselves 16-25 years with SEND.

If you are a Young Person aged 16-25 requesting some support, please complete this Consent Form.

If you are a parent/carer requesting support for your Young Person who is aged 16-25, please ask the young person to complete this Consent Form in order for us to gain consent to either work with them directly or liaise with a trusted person on their behalf.

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* 1. Your Name

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* 2. Email

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* 3. Phone Number

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* 4. Your Date Of Birth

Date

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* 5. School/College/Training

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* 6. Ethnicity

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* 7. Do you wish for us to liaise with somebody else on your behalf?

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* 8. If yes, please tell us who? If no, answer N/A

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* 9. If yes to previous question, What is your relationship to that person? If you answered no please answer N/A

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* 10. Please tell us the reason for contacting us.

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* 11. CONSENT:

Havering SENDIASS provide independent support for Havering residents. When staff support you we require your consent to speak to other professionals on your behalf. If you are happy for us to do this, please read the statement and sign below;

I hereby give my consent for Havering SENDIASS to access files held by the Havering Children and Adults with Disabilities Team. Also, where necessary to speak to other professionals to find out more information on my behalf.

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