SilverCloud consent form

Hello – you have been sent a link to this page so that you can refer a colleague for support, including access to SilverCloud.

Ben collects personal information (data) from you when you apply for support from us. We are required by law, under the GDPR, to have your consent to do this.

We will store the information safely and securely. Once this information is no longer needed we will destroy it.

Simply complete the short form and read the consent statement. If you are happy with this, please tick the box and press submit. You will then receive an email from us to confirm that we have received your consent.

Thank you!

SilverCloud referral consent form

Employer

Employer company name *

Employer full name *

Employer contact email *

Employer contact number

Individuals

Individual's full name *

Individual's email address *

Individual's contact number *

Address *

Postcode *

Date of birth *

Referral and consent

Is there a risk of suicide or self harm? * Yes
No

SilverCloud support type * Supported
Unsupported

Please state what programme(s) are required *

Reason for mental health referral *

You can withdraw your consent at any point by contacting Ben. For further information please see our privacy policy: www.ben.org.uk/ben-policies/privacy-policy/

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SilverCloud consent form

SilverCloud referral consent form