Photo/Media Consent Form

Consent from service user and the public for photo / video / audio recording

This form is NOT FOR CLINICAL purposes, only for promoting the work of BSMHFT.

If you are a service user the photo/video/audio recording won't be part of your clinical record and won't impact in any way on the care you receive.

If you have any questions about filling out this consent form, please speak to a member of staff or contact bsmhft.commsteam@nhs.net.

Purpose of consent and any description(Required)

(Please specify the event, media, training, campaign, promotional video, podcast, stock photos, social media post, publications, etc. the consent is for.)

Our communication channels

The communication channels are places or platforms where your photo/video/audio recording may be used.

Please choose the channels you would be happy with:

Other communication channel(Required)

Details of service user / carer / member of public etc.

First name(Required)

Other Are you happy to be identifiable(Required)

Please specify your other preference

Telephone / Mobile(Required)

I understand that the photo/video/audio recording to which I have agreed may be reproduced to illustrate, share and promote the work of Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT).

I understand that I can withdraw my consent for the use of my photo/video/audio recording at any time by emailing bsmhft.commsteam@nhs.net or writing to: Communications Team, Birmingham and Solihull Mental Health NHS Foundation Trust, Uffculme Centre, 52 Queensbridge Road, Moseley, Birmingham, B13 8QY. On receipt of my direction to withdraw my consent, BSMHFT will delete copies of my photo/video/audio from the image library, and I understand my image will not be used for future publications.

Note: Withdrawing your consent will not apply to material already published as BSMHFT cannot control or recall published material (for example printed materials and social media).

All photos/videos/audio recordings will be held on file for a period of three years*. These files are held securely on our Trust systems and are only accessible by appropriate members of staff.

*After three years the original photos/videos/audio recordings will be deleted. Note: BSMHFT cannot control or recall published material (for example printed materials and social media)

Please note that hard copy of this form will be posted out in the first week of the month.

Email Communication(Required)

Details of BSMHFT staff requesting this consent form

Staff – First name(Required)

Staff – Surname(Required)

Staff – Job title(Required)

Staff – Service and work location(Required)

NHS email address(Required)

You will receive a copy of this form.

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Unique Reference

Please provide your email address so that we can respond to your feedback. Please do not share any additional personal details. Thank you.

How can we improve this page?

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Page Name

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Page URL

Please complete required fields above to proceed. Please check you have entered all information correctly.

The Trust uses a number of privacy policies, to access them visit our polices(opens in a new tab) page

Consent from service user and the public for photo / video / audio recording

This form is NOT FOR CLINICAL purposes, only for promoting the work of BSMHFT.

Our communication channels

Details of service user / carer / member of public etc.

Contact details

Details of BSMHFT staff requesting this consent form

Give feedback on this page