Thrive Counselling

Useful information and questionnaires to be completed prior to your first session

Consent form

Consent for Hull and East Yorkshire Mind to share and use my information

What are we asking you to do?

We would like to help you, however to do this we sometimes need to share your personal details e.g., date of birth, name and address, health issues, ethnicity, medication, etc. as well as information about the support you receive from us and the main thing that worries you. This will help us to make sure you get the support you need.

Do I have to fill out the consent form?

It is important for you to fill out the form, even if you choose to not share any of your personal information. We are legally required to keep a record of the decision you make about who can or can’t share your data with. This form will be a clear record of your decision about your data.

Do I have to agree to consent?

We can still offer you the additional support if you don’t agree to share any of your personal details, but we may not be able to offer you the best support available if we cannot share your information with other local services.

We will only disclose your information to those third parties which you have consented to us contacting, except in the following circumstances:

  • if we consider that your health and safety is at risk or there appears to be child protection or vulnerable adult protection issues;
  • if we have reason to believe unlawful or potentially harmful activities are taking place;
  • if we are permitted or required by law to disclose such information; or
  • if we consider there to be a risk of suicide or self-harm if the information is not disclosed

What if I change my mind later on?

You have the right to withdraw consent in part or fully at any time either verbally or in writing. You can also agree later to give consent on something you have not wanted sharing or withdrawn consent for previously.

    Young Person's Name (required)

    Young Person’s Date of Birth (required)

    Parent / Carer's Name (required)

    Parent / Carer's Date of Birth (required)

    Phone Number (required)

    Email Address (required)

    Date (required)

    I give permission for staff at Hull and East Yorkshire Mind to discuss any aspect of my care and support needs with the following: (required)

    Is there an agency or anyone who you do not wish us to contact(required)

    If yes, who?

    By submitting this form, I agree that Hull & East Yorkshire Mind may discuss my support with the agencies I have indicated above, acknowledge the circumstances in which information may be disclosed without my consent, and agree to my personal data being used and processed.

    Counselling delivery

      Young Person's Name (required)

      Young Person’s Date of Birth (required)

      Parent / Carers Name (required)

      Date (required)

      Please can you let us know which type of therapy session you would prefer by ticking all the boxes that apply? There may be a longer wait for face to face sessions. Please note all face to face sessions will take place either at Hull and East Yorkshire Mind (HU3 1YA) or at your School or College and will be between Monday-Friday.