Mental Health Support Consent Form

Full Name

Date of Birth

Address Contact Number Email

Consent

I acknowledge that I have been informed about the nature of mental health support, the type of assistance to be offered, and my rights to confidentiality and privacy. I understand the limits to confidentiality, including situations where disclosure may be required by law or to prevent harm.

I confirm that I have read and understood the information above and voluntarily consent to receive mental health support.

Questions or additional information (optional)

Signature

Date