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Online Application Form



Information about you:

In order for me to be able to fulfil my responsibilities as a course facilitator I will need to record personal information about you on an application form. This information includes your name, address and contact details, and GP practice. Under an identifying code I will also takes notes of ‘assessment information’, that is relevant medical information and aspects of your personal social and family history that you choose to share with me. This application form will be kept in a locked filing cabinet and will not have your name on but an identifiable code.

Your contact details will be used to contact you. Other personal data such as your name, address and/or date of birth will be used to verify your identify if there is a need to contact your G.P. or a request for access to personal data from yourself or your representative or legitimate legal instrument such as a court order.

This personal information will be held for a period of three years after the cessation of our course relationship, except where there is a mutually agreed decision to retain it for longer or where I believe that it is in my best professional interests to do so.

Your contact details alone will be shared in exceptional circumstances with my supervisor or other named agent in the event that I am incapacitated so that they can contact you to explain the situation.

Information about sessions and our work together:

Also I will record notes of each group session; all details will remain anonymous unless I have your explicit permission to share.

I may make information from these notes available to legitimate third parties under the following conditions:

  • Receipt of a request from you or your representative, and where the release of the notes is not judged by me as likely to cause you significant harm or harm to another person
  • Where there is a specific legal requirement for me to do so
  • Where there is an ethical duty for me to do, for example to avoid serious harm to yourself or another person, including the safeguarding of children or vulnerable adults.

Records of contact between us:

I will hold your name and telephone number on my mobile phone until our course relationship ends and then I will delete it from my contact list. However the phone will retain summary records of calls made to or from your number (date and duration) and any recorded messages for three years. I run a WhatsApp Peer to Peer support group during the week for all individuals that have attended an SOB group; if you would like to join this I will ask for your written permission at the start of your course.

Your Rights:

You have the right to ask to see any information held by me about you. To do this please either ask me, or submit a request in writing. You also have the right to ask for information that you believe to be incorrect to be rectified. I will endeavour to provide you with the information requested within four weeks.  If I become aware of a situation where your personal information may have accidently or maliciously been obtained by a third party I will notify you within three days.

If you are concerned about the way that your information is being held please discuss this with me. If you are still unhappy you have the right to complain to the Information Commissioners Office.