CONSENT FORM

Please take time to read this carefully. It forms part of the agreement between you and your therapist,   Patrizzia Ciaccio when you attend an appointment. You will be requested to sign 2 copies of the Consent and Disclosure form and be given a copy and the other copy will be kept with your records.

Data Protection and Storage of Data

The Data Protection ACT 1998 requires that psychological and medical data is treated with strict confidentiality. Patrizzia Ciaccio adheres strictly to the ethical and confidential guidelines of professional practice. From the 25th May 2018 a new law called The General Data Protection Regulation (GDPR) came into effect. GDPR is designed to give you more choices in how you are contacted and how your personal data (name, contact details, email address and case histories) is processed.

As a sole practitioner/therapist I am registered with the Information Commissioner’s Office (ICO)  as a ‘data controller’. I will only contact you for consultation (mobile/landline phone numbers, emails, letters) during our agreed contracting period and I will not pass your details on to any third party. Electronic Data and Paper Records: Electronic data is password protected on the computer and involves 3 stages: - (1) The computer is encrypted and can only be opened by using a removal disc to activate access with a password, (2) password protected to gain access into electronic data and (3) password protected files including assessment reports, interim reports and discharge reports via referral agencies all require encryption passwords to open them when sent by email attachments or via an organisational electronic login portal. Confidentiality is maintained by using an allocated case code number.    

The computer and any Paper records are stored in a locked filing cabinet in a locked office in my residential clinic. No other person has access to client records. The property also has a security alarm system that is activated when the premises is empty.

I confirm that I have read the Data Protection and Storage Data information and understand the above.  I understand that I can evoke my consent at any time during treatment by informing the therapist in writing.

Name in Print

Signature

Date

 

 

 

 

 

 

 

Form should also be signed by parent or guardian if client is under 18 years of age.

Download form (word document - opens in new window)

 

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