Personal Information Form

Name
Membership Number
Authorisation Code
GP Name
Surgery Address
Name
Address
Please give some comments if you answered YES or MAYBE to the above
CONFIDENTIALITY AND INFORMATION SHARING:
Information discussed between the young person/adult and myself during session is confidential, however there may be times that I need to break confidentiality in order to keep a young person/adult safe or to keep others safe. For example, if a young person/adult shares, they are feeling suicidal I will need to ensure parents/ carers/next of kin, are aware of the risks and possibly other professionals or agencies. If a young person/adult discloses, they are having thoughts with intent in relation to harming others I would need to share this with relevant agencies/ professionals. With regards to self-harm I always encourage young people/adults to discuss this with parents/carers/next of kin and involve supportive others in a risk management plan, however there are times I feel this would potentially increase risk and that work with both the young person/adult and family needs to be carried out first.

SAFEGUARDING:
It is my responsibility to ensure I safeguard all young people/adults I work with and share any safeguarding concerns with social services. For example, if a young person disclosed, they were being physically, emotionally, sexually abused or neglected, I have a duty of care to report this. If you want more information on abuse or have any questions please don’t hesitate to discuss with me or you can look on the NSPCC/SCIE website for further information.

FAMILY WORK:
Particularly with younger children I recommend parents being involved in the sessions as much as possible. Although sessions are confidential, I try to encourage young people to involve parents/carers in the work that we do where appropriate. When working with adults I encourage supportive others to be involved in their care if appropriate.

INFORMATION I COLLECT ABOUT YOU AND HOW I USE IT:
Upon starting therapy, basic personal information will be collected for contact and identification reasons. During our therapy meetings, an assessment of your psychological health will be completed, and notes will be taken during sessions. These will include personal and sensitive details about your life. The assessment and notes are used solely for the delivery of a therapy service to you.

YOUR RIGHTS:
You have rights relating to the information I hold to verify the accuracy or to ask for them to be supplemented, deleted, updated or corrected. You have the right to request a copy of the information that I hold about you. If you would like a copy of some or all of your personal information, please email or write to me via the contact details stated in this agreement. Information will be provided to you within 30 days.
I want to make sure that your information is accurate and up to date. You may ask me to correct or remove information you think is inaccurate. You have a right to request the transfer of your data to another individual or company.

HOW LONG WE KEEP YOUR INFORMATION FOR - DATA RETENTION:
Your information is kept for the time necessary to provide the therapy service requested, however outside of this I will hold your details and session notes for a period of 7 years following the end of treatment to comply with legal obligations that are placed upon me by my insurers. In the case of a child under 13 then records will be kept 7 years after they reach the age of majority (18). After this date, all data will be securely deleted.

SHARING OF DATA:
There may be times where your information needs to be shared with 3rd parties. I will explicitly ask your consent before doing so, and the data will be sent to 3rd parties securely. With regards to safeguarding there may be certain situations where a judgement is made that it is not safe to gain consent prior to sharing information, in these circumstances the law permits me to do so.

SECURITY OF YOUR DATA:
Sessions notes will be anonymised and any electronic information password protected where possible. All will be kept securely and confidentially in line with the data retention policy as stated above.

LAWFUL BASIS FOR PROCESSING YOUR INFORMATION:
The lawful basis for my holding and using your information is in relation to the delivery of a contract to you as a health care professional. As an accredited member of BABCP and NMC I operate under a strict code of confidentiality.