Personal Information Consent Form
1. I, _______________________________________ of
<Insert name of adult whose information is being shared >
__________________________________, __________________, BC
<Address > <City>
give consent (permission) for Community Living BC (CLBC) to:
Collect (CLBC getting your information from someone)
Disclose (CLBC giving your information to someone)
the following personal information: _____________________________________________
<What information is being shared? (e.g. Personal Support Plan, Psychological Assessment)>
for the purpose(s) of: __________________________________________________________
<Why is the information being shared? (e.g. Eligibility Determination, Support Planning) >
2. This personal information will be:
□ collected from
<The name of other organization / person sharing information with CLBC>
disclosed to
<The name of other organization / person receiving information from CLBC>
Print Form
3. I am acting on my own behalf; or
I, _____________________________, am acting on behalf of
<Insert name of legal representative>
_______________________________________ and
<Insert name of adult whose information is being shared >
I have provided evidence that I have the legal authority** to do so; or
The following statement should be taken from a person supporting an adult:
I, ______________________________, have explained this consent form and
<Insert name of person supporting the adult>
how the information described on page 1 will be collected, used and/or
disclosed with __________________________ who has communicated that they
<Insert name of adult being supported>
approve the sharing of this information.
** What do you mean by “legal authority”?
- If a person is under 19 years of age their legal guardian has the authority to
consent on the person’s behalf.
- If a person is 19 years of age or older and has an appointed Committee or
Representative named within a Representation Agreement, that Committee
or Representative has the authority to consent on the person’s behalf.
This consent is in effect from the date signed until ________________________________.
<When do you want this consent form to end?
The maximum length is one year.>
_________________________ _________________________
Date Signature
The personal information requested on this form is collected under the authority of and will be used for the purpose
of administering the Community Living Authority Act and/or the Freedom of Information and Protection of Privacy Act
(FOIPPA). Under certain circumstances, the collected information may be subject to disclosure as per the FOIPPA.
Any questions about the collection, use or disclosure of this information should be directed to the CLBC’s Privacy
Officer, the Manager of Quality Assurance, located at CLBC Headquarters, 7th Floor, Airport Square, 1200 West
73rd Avenue, Vancouver, BC V6P 6G5. Contact Number: (604)664-0101 or Toll Free at 1-877-660-2522.
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