Derby Women’s Centre Service User Consent Form

Please download the form to complete below:

Service User Consent form

A preview of this form is below:

General Data Protection Regulation – GDPR
DWC Service User Consent Form
to be completed after reading the privacy statement
1.      What is consent?
Consent means that you give us permission to record and use the information you give us

Why do I need to consent?

Derby Women’s Centre (DWC) needs your consent to comply with the General Data Protection Regulation (GDPR).  DWC establishes a high standard for consent enabling us to build trust and offer you genuine choice and control over how we use the information you have supplied (sometimes known as data).

You do not need to consent, but it may affect one or more of the services we are able to offer you.  For example, if you would like to access a service i.e. Counselling or attend a course or activity; we need to pass your name on to the Counsellor/course provider/tutor.  We have Counsellors/Therapists/tutors/volunteer facilitators/others who are independent or from outside organisations providing a range of services/therapies/activities/courses here and they rely on this information.  If you do not provide this information, you will not be able to attend unless there are special circumstances (protection) that excludes you from this.  DWC will take the minimum amount of information from you (basic details).  In this case it would be your name, address and contact telephone number.

2.      Privacy
The legal reasons we have for processing your data:
1.       Make a decision regarding eligibility for different services/therapies/activities

2.       Provide support and guidance to women through 1-2-1 and or group services/activities/therapies

3.       Allow analysis of anonymous data for operational and evaluation purposes for both DWC and Funders

4.       To keep you informed

Sharing your data
We will not share any of your personal information with funders or any other organisations without your written or verbal permission.  Where you have given us your permission, you may withdraw it at any time.

Everything you tell us will be treated in the strictest of  confidence unless:

·         The information indicates a serious risk to yourself and or a child or another person may be at risk

·         A serious threat is made to a third party or it is noted that another person may be at risk

·         Disclosure from DWC is required by law or is necessary in the interest of the public

Storage, retention and deletion
Your details are stored electronically on our database and on paper which is stored in locked filing cabinets


Your details will be deleted from our database and files:

1).  If you have not engaged with us for 5 years

a)  For counselling purposes records will be held for 6 years

b)  Domestic Violence/Loneliness purposes records will be held for 6 years

c)  Please note that some funders require us to keep information for up to 10 years

2). If you withdraw consent.  You can do this in any of the following ways:

a)  letter to The Data Controller, Derby Womens Centre, 4 Leopold Street, Derby, DE1 2HE

b)  email (The Data Controller)

c)  In person at reception, between 9.30am and 4.40. Monday to Thursday.  Please note due to the current Coronavirus the centre is temporarily closed.  Please use the above methods to withdraw consent.

1.      Preferences
DWC sometimes need more than just your basic details to refer you to other agencies. For example, if you would like support with Domestic Violence and Refuge we would need information about your income and benefits.  If there is a particular agency that you do not want us to refer you to please identify it/them here:


I agree to be contacted by Derby Women’s Centre by:
         Telephone  (enter tel no)
        Email (enter email address)
        Text/SMS (enter mobile no)
        Letter (enter address)
        Can DWC leave message on home phone Please circle choice:             Yes                No
        Can DWC leave message on mobile phone Please circle choice:             Yes                No
        Do you agree to have your photograph taken for publicity purposes?
        I am aware that I can review my consent at any time

Please indicate your preferred method of contact here  ­­­—————————————————————–

Privacy Statement
        I have read and understood the Privacy Statement
Name (please print)
2.      Monitoring Information (optional)
This information can be useful when we are applying for funding for new projects, it shows funders the geographical areas that we are reaching women from, their age groups and backgrounds.
Year of birth Postcode
Ethnicity (please state your ethnic background)



Please Download form, complete and return to:


Domestic Violence:


Other services:  


Please download the form to complete below:

Service User Consent form