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

West Mercia Women’s Aid
Consent Form CYP

Working agreement, please read prior to completing the form

  • I commit to attending each session on time or to inform my CYP 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 CYP 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.)

Documents to read

Please visit and read our supporting documents page before completing the form.

Consent Form: Children & Young People Services

Please complete the form below

I confirm that I have read the agreement to the left and the following files:

COVID-19 Agreement (1)

COVID-19 Agreement (2)

COVID-19 Agreement (3)