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24hr Domestic Abuse Helplines: Herefordshire & Shropshire: 0800 783 1359
Telford & Wrekin: 0800 840 3747
Worcestershire: 0800 980 3331

West Mercia Women’s Aid
Consent for CDAS service

West Mercia Women's Aid > Forms: Consent for CDAS service

Working agreement – Please read prior to completing the form.

I commit to attending each session on time or to inform my CDAS Worker as early as possible if I cannot attend or I am running late.

I understand that only a named person will drop off/collect my child. If this is not me, I have made CDAS Workers aware of arrangements prior to collection.

I understand that if my child becomes unwell during a session I will be contacted on the number given above. In the event that my child becomes seriously ill I authorise WMWA staff to contact a medically qualified practitioner or hospital for my child to receive treatment. I consent for First Aid to be administered if necessary.

I fully understand the service I or my child/young person has been referred for. I understand that support is confidential unless there are safeguarding concerns, this has all been explained to me.

I understand that WMWA may speak to other agencies regarding the support that I or my child/young person is receiving in order to gather more information or to pass on information in order to best support. (E.G school staff, Social Worker if open to social care, additional Support Staff) I understand I will be made aware of this prior to contact being made.

I give permission for information that does not identify me or my child/young person to be used for case studies, to evidence the work of WMWA and secure future funding. I understand that any information used will remain confidential, no information that identifies me or my child/young person will be published. I give permission for WMWA to record anonymous data and support outcomes (My Star scores) and report these to our funders, for monitoring purposes. (I understand I can opt out of this and my decision will not affect the support my child receives.)

I confirm that I have read the following information:

Covid-19 checklist

  • Information for parents
  • Protocol for face to face sessions
  • Track and Trace client
  • What to expect when seeing your CDAS worker

Consent for CDAS Service Form

Please read the working agreement then complete the form below

I have read and agree to the protocol in place for sessions, and have been informed that I can request the full Risk Assessment, I understand that my child’s worker will update me of any changes to this in-line with government advice during the Covid-19 pandemic.

I have informed my worker of any additional risk factors that may increase mine or my child’s and families risk by taking part in sessions delivered by a CDAS worker.

I agree in the event the CDAS worker, member of the group or a close family member contracting Covid-19, confidentiality will not be able to be fully maintained and mine or my child’s details, due to Track and Trace measures the Government have put in place, will be shared with the appropriate agencies. (WMWA has a duty to inform you immediately if this occurs)

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