Consent for Contact (C4C) - Expression of interest form

Your name:

Are You over 18?  Please type: YES or NO: 

 

Are you currently receiving services through South London and Maudsley NHS Trust (SLaM)?

             Please type: YES, NO, Don't Know: 

 

Please provide your preferred contact details below:

Which clinical team do you visit? Please give details below:

                Do you have a Care Coordinator?                   

                Please type: YES, NO, Don't Know: 

 

If you have one, please give the name of your SLaM Care Coordinator or SLaM Doctor, below:


Are you happy for researchers to contact you when discharged?

              Please type: YES or NO:

Please Note: This form will be sent securely over the internet to the C4C research team and by submitting this form you are giving your consent for someone from the C4C team to contact your clinical team and to ask them some basic questions about you. A member of the C4C team will then contact with you with more information.