Vulnerability Consent form - Corporate and Legal Collections

If you’re having difficulties repaying a debt due to mental health reasons, we understand and are here to help. There are two forms below which are designed to give us more information. One is a consent form, where you’re able to give your consent for us to receive information from a medical professional to support your situation. This is below. The second form will follow after submission of your consent form and is to be completed by your health or social care professional.

Consent form

You have been asked to complete this form because you told us that you have a mental health problem; and said this mental health problem makes it difficult to repay your debt. We have suggested that medical evidence is collected about your mental health situation; and this is collected from a health or social-care professional who kows you (you can choose the professional). The medical evidence will be used by the company that you owe money to; and to help them decide what to do about your debt.

You should read this form – it contains important information; then sign the form if you agree that evidence can be collected; and follow the instructions on what to do next. If someone else looks after your money matters, they can signh this form for you. (They will need to prove they are legally allowed to sign for you).

Read below: important information

What medical evidence will be collected about me?
Once you choose a health or social-care professional, they will be asked: – if you have a mental health problem that affects your ability to manage your money; and whether you have any other circumstances that need taking into account, and for details of the history of your mental health problem.

Who will collect this evidence?
Your debt adviser will collect this evidence for you.

How long will my evidence be kept for?
The Data Protection Act (1998) says it can be kept for as long as it is: – an accurate description of your situation; relevant for the type of decisions that need to be made; and up to date. If your information isn’t accurate, relevant, or up to date, it should be destroyed.

Sign below if you agree that evidence can be collected

Are you the person with mental health problems?

Yes - please write your contact details below

No - please write their details in Section A and your details in Section B below

Section A

Name(Required)

First Last

Phone

Address(Required)

Street Address Address Line 2 City County / State / Region Postcode

Section B

Name

First Last

Phone

Address

Street Address Address Line 2 City County / State / Region Postcode

We will need to see evidence of authority to act on this person's behalf

Section C

Please sign this form. Only sign this form if you agree that medical evidence can be collected. I agree that a health or social-care professional can fill in the Debt and Mental Health Evidence Form about the mental heatlh of the person named in Box A (above).

Signature(Required)

Date(Required)

Name

First Last

Decide which health or social-care professional you want to complete the following form to provide evidence.

This is your choice. You can suggest a nurse, general practitioner (GP), psychologist, social worker, psychiatrist, occupational therapist, or another qualified worker.

Name of professional(Required)

Phone

Address

Street Address Address Line 2 City County / State / Region Postcode