Consent and confirmation - Over 18's

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This field is for validation purposes and should be left unchanged.

Assessment Attendee

Name*

First Last

Date of Birth:*

Age*

Gender*

Male

Female

Non-binary

Other

Preferred Pronouns*

He/His

She/Her

They/Them

Prefer not to say

Next of Kin contact details

In case of an emergency who do we contact?

Title*

Name*

First Last

Relationship to you*

Preferred Pronouns*

He/His

She/Her

They/Them

Prefer not to say

Daytime phone number*

Mobile phone number*

Information sharing with professionals

We ask for your GP (or other relevant professional) contact details so that, with your consent, we can share information about your assessment where it would support your care and wellbeing, or help coordinate with other professionals involved. Please note that we will not contact your GP or any other professional without your explicit consent, unless we have safeguarding concerns that require us to do so under our Safeguarding Policy and legal obligations.

I consent to bibic contacting my GP or other relevant professionals involved in my care, where this may support my assessment or ongoing wellbeing.

Yes, I give my consent

No, I do not give my consent

GP/Professional name and address

Street Address Address Line 2 City County Postal code Country

Phone

Email

Payment

I am eligible for military discount:

Yes

No

* If eligible please email evidence of this to familyservices@bibic.org.uk

Please use your invoice number in the payment reference when paying via bank transfer.*

Option 1 – Paying the full amount

Option 2 – Pre-agreed payment option with family services

* Please note: Full cost is required to be paid two months before the assessment day.

Signature*

By signing this form I confirm that the information that I have provided is correct.

Signature date

Consent and confirmation – Over 18’s

Please complete the required information in full within two weeks – if you need any help, please contact 01458 253344.

Consent and Confirmation Form – Over 18’s

Assessment Attendee

Next of Kin contact details

Information sharing with professionals

Payment