This form should be read to the beneficiary or their guardian in their mother tongue.
It should be clearly explained to the beneficiary that he / she can choose any or none of the options offered.
I authorize to communicate the information relating to the incident that I declared to him as explained below:
I understand that by giving my authorization below, I allow (name of your organization) to communicate to the service provider (s).
I have designated the information specifically relating to my case, contained in my report incident,
in order to be able to benefit from assistance according to my security, health, psychosocial and / or legal needs.
I understand that the information communicated will be treated confidentially and with respect,
and will only be disclosed if it is necessary to enable me to receive the assistance I have requested.
I understand that the disclosure of this information implies that a member of the organization or service checked below can speak to me. I have the right
to change my mind at any time about the disclosure of information to the body / contact person named below.
Message sent !
Please keep your phone, an administrator will contact you shortly for more details.