I hereby give my permission for the information provided on this form to be given to The Amber Foundation as stated on page 1 of this form.
I also give my permission for the provider to contact any other agencies regarding my support needs, health / psychiatric history and details of any court convictions / reprimands.
I understand that this information will be used by the provider for assessment purposes only and that all written and verbal information concerning this referral will be treated as strictly confidential by Amber.
I understand that, if my application is successful, this information will be held on file and I will have the right of access to it.