Shelf Help for Eating & Body Image

Shelf Help for Eating & Body Image: Books to support you to understand and manage your health and wellbeing

If you have any questions please contact us: david.rawlings@stroud.gov.uk or hollie.jones20@nhs.net

This form must be completed and received by Stroud District Council (Community Health & Wellbeing Team) and Berkeley Vale Primary Care Network (BV PCN) before a young person can receive a book.

Stroud District Council (SDC) and Berkeley Vale Primary Care Network (BV PCN) are working in partnership with The Cotswold Book Room.

We recognise the ability of competent young people to also provide consent. As such, this form should be signed by the young person and their parent or legal guardian if under 18.

Data Protection: SDC processes personal data in accordance with the General Data Protection Regulation 2016 and the Data Protection Act 2018. For information about how we process personal data, please refer to the Council’s Privacy Notice which can be found at: stroud.gov.uk/council-and-democracy/about-the-council/access-to-information/privacy-and-cookie-policy/privacy-notice

You can withdraw your consent by contacting us:
david.rawlings@stroud.gov.uk

1. Do you understand how to access information about our privacy policy?

SHARING YOUR INFORMATION:

We take your privacy seriously and will never sell your information to third parties.

We are required by law to share information with relevant authorities if we become concerned about someone’s safety.

2. Do you understand how we share your information?

CONTACTING YOU:

Whilst working with SDC & BV PCN we may need to contact you with information about the specific project you are involved in. We would like to use your email address in order to get messages to you when you really need them.

3. Are you happy to receive information by email?

COMMUNICATIONS:

SDC & BV PCN would like to stay in touch with you. We won’t send you tonnes of stuff but the types of things we might send include: information about opportunities to be involved with our projects and relevant information about partner organisations. You can opt out of receiving information at any time.

4. Are you happy to receive communications from us by email?

5. YOUNG PERSONS DETAILS:

The information below is required to be involved in the project:

Full Name
First Line of Address
Town
Postal code
Email Address
Phone number
Nickname
Pronouns
Date of Birth
Age

6. Please tick which surgery the young person is registered with:

7. Please choose the statement that best describes the young persons current situation:

Have seen a GP or other health professional
Seeing a counsellor eg, Teens In Crisis, Young Gloucestershire
Are on the waiting list for an NHS service eg, Brownhills / CAMHS
Receiving clinical treatment from an NHS service eg, Brownhills / CAMHS
Discharged from an NHS service or other formal support eg, Brownhills, CAMHS, counselling

Additional information

8. CONTENT GUIDANCE:

These books explore aspects of psychology and mental health, including depictions of eating disorders, self-harm, suicide and suicidal ideation – this list is not exhaustive.

Please read with care and seek support from a trusted person if you need to.

Please tick to confirm that you have read and understood this guidance:

	Yes	No
Young Person	Young Person Yes	Young Person No
Parent or legal guardian	Parent or legal guardian Yes	Parent or legal guardian No

9. Shelf Help for Eating & Body Image

Please tick below to indicate the title of the book that you would like to receive, free of charge

CONSENT FOR PROJECT INVOLVEMENT:

Consent is required before a young person can fully participate in this project run by SDC, SBV PCN & The Cotswold Book Room.

10. PARENT / GUARDIAN DETAILS:

A parent or guardian of a young person under 18 will need to enter their details below and complete the consent section.

Full Name
Relationship to young person
Address
Phone number
Email address

11. Parental Declaration (for young people under 18)

I confirm that I have parental responsibility for the above young person and consent to them taking part in this project run by SDC, BV PCN & The Cotswold Book Room.

Full Name
Date (DD/MM/YYYY)

12. Consent to share delivery information with bookshop

We will need to share a name, address and the chosen book title with the bookshop so that they can process the order and arrange delivery.

Please tick to confirm if a name, address and the chosen book title can be sent to the bookshop.

Agree
Disagree

13. Please write a name in the box below as you would like it to appear on the package.

14. Young Persons Declaration

I consent to taking part in this project run by SDC, BV PCN & The Cotswold Book Room. *

Young Person's Full Name	*
Date (DD/MM/YYYY)	*