AUTHORITY TO SHARE

I am: [tick box] *

A sex worker completing this form for myself A peer educator completing this form on behalf of a peer

Who would you like us to share information with? *

Sex worker community Legal support Police Other [please specify below]

Preferred Name *

Yes [please specify below] No Unsure

Name

My workplace: *

Yes [please specify below] No Unsure

My location at the time of the incident: *

Yes [please specify below] No Yes

Is there any information you would NOT like shared? [short answer] *

A Vixen staff member may need to contact you to verify your consent. What is the best way to contact you? [short answer] *

I understand how and why certain information about me may be shared with other people or services. I understand this and give my consent for the information to be shared: *

Yes No

I am a Vixen staff member and I have discussed with the peer how and why certain information may be shared with other people or services. I am satisfied that this has been understood and that informed consent for the information to be shared has been given.

Yes No

Name

Date / Time