I understand that personal information gathered about me, and my circumstances supporting, the care arrangements that arise from it, may need to be shared with other agencies and that those agencies will hold both paper and electronic records.

I agree to the agencies named below sharing and/or seeking information about me with each other. The information should only be used for the purpose of providing a service to me; however I understand that agencies may use information for statistical purposes, but this will not identify me.

My agreement is based upon my understanding that due care will be taken to disclose only that information that each organisation needs to discharge its responsibility to deliver a service to me.

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I understand that if I do not agree to information about me and my circumstances being shared with other agencies it may result in my not receiving services which I may otherwise receive. I understand that I am free to contact those agencies myself in order to access those services.

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If the person is not able to sign or lacks capacity to consent:

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