Consent Policy

This policy is consistent with the guidance from NHSE, GMC and CQC

Introduction

Before you give consent to assessment/treatment we will help you to understand:

• Why the assessment/treatment is advised
• Exactly what the assessment/treatment involves
• What the risks/side effects/complications of the assessment/treatment are
• What the alternatives are or the consequences of not having the assessment/treatment

We will give this information to you appropriate to your age and understanding.

Who can consent

You can give consent if you are ‘competent’ whatever your age. To show competence you must:

• Have a general understanding of what decision you need to make and why you need to make it
• Have a general understanding of the likely consequences of making or not making the decision
• Be able to understand, retain, use and weigh up the information relevant to the decision
• Communicate your decision – whether by talking, using sign language or any other means

Even if you are under 16 and/or not fully competent to do all the above we will seek your views and take them into consideration wherever possible.

If you are under 18 your parents/guardians can consent on your behalf if they have parental responsibility.

Author	Publication date	Review date
Karen Street	October 2020	October 2023

Information and Consent Form

Name of child/young person:

Referred for discussion by:

Exeter Paediatric Integrated Care (EPIC) Solutions are a team of health professionals led by a consultant paediatrician and consultant child and adolescent psychiatrist. We are funded by, and working with, the Devon County Council Education Inclusion Team over the academic year 2020-21. Our role is to provide a holistic assessment of children and young people who have been identified by the Education Well Being (EWB) team as having physical and/or mental health needs that are limiting their ability to attend school and/or engage with education. This assessment may be virtual, based on information already available, or it may be face to face. Based on the assessment we will provide verbal and written advice to the EWB team to support any identified needs in the education setting, we will also link with or refer to NHS services where appropriate, including your GP. You will also receive your own copy of any written reports. Where further assessment and/or input is not immediately available on the NHS but considered essential by the EWB team to support access to education this can be undertaken in the short term by EPIC solutions.

Please provide consent to our involvement (delete/circle as appropriate):

I/we consent to the education well being team discussing my/my child’s difficulties in school with the health professionals in EPIC solutions:

Yes/No

I/we consent to the health professionals in EPIC Solutions accessing existing health information on me/my child and liaising with health professionals already involved:

Yes/No

I/we consent to a face to face assessment with a health professional in EPIC if this is the best way of assessing my/my child’s physical and/or mental health difficulties in school:

Yes/No

Please sign below:

Child/young person (optional):

Signature: ………………………………………………………………………………………………………………………………………………….

Name in print: …………………………………………………………………………………………………………….………………………..

Parent/guardian:

Signature: ………………………………………………………………………………………………………………………………………………….

Name in print: ………………………………………………………………………………………………………………………………………

Relationship to child/young person: …………………………………………………………………………………………………….

EWB team member requesting EPIC input: …………………………………………………………………………………………

In order for EPIC to contact you if needed please complete the below:

Address:

Preferred contact number:

E-mail address for communication:

Using personal information

The information you provide to EPIC solutions is confidential. Any personal information we hold about you/your child is stored and processed under our data protection policy, in line with The Data Protection Act 1998 and the General Data Protection Regulation 2018. Information is retained in line with Department of Health recommendations.

Information may be shared with the appropriate staff members working in our team and they understand their legal responsibility to maintain confidentiality and follow practice procedures to ensure this. As described above we may also share your information provided to EPIC solutions with your/your child’s GP, Education services, CAMHS/PCAMHS, Social Services, or other health professionals in order to access the most appropriate support for you/your child. We will ask for your consent to do this.

There may be instances when we need to share information without your consent such as, when there is a legal obligation for us to do so or when the information concerns risk of harm to the patient, or risk of harm to another child or adult. We will discuss such a proposed disclosure with you unless we believe that to do so could increase the level of risk to you or someone else.

For more information about how EPIC solutions will handle your personal information please refer to the terms and conditions on our website epicsolutions.org.uk. If there are any further queries please  contact  the data controller for EPIC Solutions on

Patient Registration Form

In order to accept this appointment and confirm attendance please complete the form below and return by e mail to .

If you have difficulties with this please confirm by e mail and bring this completed form with you to the appointment.

This policy is consistent with the guidance from NHSE, GMC and CQC

Introduction

Before you give consent to assessment/treatment we will help you to understand:

• Why the assessment/treatment is advised
• Exactly what the assessment/treatment involves
• What the risks/side effects/complications of the assessment/treatment are
• What the alternatives are or the consequences of not having the assessment/treatment

We will give this information to you appropriate to your age and understanding.

Who can consent

You can give consent if you are ‘competent’ whatever your age. To show competence you must:

• Have a general understanding of what decision you need to make and why you need to make it
• Have a general understanding of the likely consequences of making or not making the decision
• Be able to understand, retain, use and weigh up the information relevant to the decision
• Communicate your decision – whether by talking, using sign language or any other means

Even if you are under 16 and/or not fully competent to do all the above we will seek your views and take them into consideration wherever possible.

If you are under 18 your parents/guardians can consent on your behalf if they have parental responsibility.

Author	Publication date	Review date
Karen Street	October 2020	October 2023

Patient Registration Form

In order to accept this appointment and confirm attendance please complete the form below and return by e mail to .

If you have difficulties with this please confirm by e mail and bring this completed form with you to the appointment.

General Information:

Name: Preferred Name: Date of Birth:		Address:
Ethnicity:		Religion:
NHS Number:		GP:
Gender Identity: Preferred Pronouns:		E-mail: Phone:

Communication:

Question	Fill in / Delete or circle as appropriate
Who do you live with? Who holds Parental Responsibility for you?
How would you like us to communicate with you?	Post / Phone / Mobile / Email / Text
Would you prefer a method of communication not listed, if so what?
I give my consent for email correspondence	Yes / No
Does anybody have any communication or access needs? (e.g. format other than standard print, dyslexia needs, translation services, signing or lip reading interpreter, registered disability or sensory need, or other access need?)	Yes / No
Details:
Who else should we communicate with?	Parent or carer / School / GP / Professional
And what are their contact details? Parent/carer: School: GP: Professional:
Should we copy all correspondence to your GP?	Yes / No
Any Comments:
EPIC operates as a Multidisciplinary team. All young people are discussed at team meetings to allow oversight of our work and to ensure that care plans are appropriate. All information is kept confidential by the team. Do you consent to this level of information sharing?	Yes / No
Any Comments:
Do you understand our approach to confidentiality and safeguarding?	Yes / No

By signing this form, I confirm that the information above is correct and I agree to the terms and conditions (available on www.epicsolutions.org.uk and attached to your appointment e-mail).

Person	Name in Print:	Signature:
Child / Young person
Parent / Guardian
Parent / Guardian

Date:

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