Consent Form — Crystal Pathways

❖ Consent FormNeurodevelopmental Pathways

Step 1 of 520%

Step 1 of 5

About you

Basic details to identify your consent record and link it to your assessment

ℹThis consent form covers your neurodevelopmental assessment with Crystal Pathways at Brighton Health Clinic. Please read each section carefully. You can ask questions at any point by contacting your clinical team.

Your details

First name *

Last name *

Date of birth *

Email address *

Phone number

Pathway / referral source

Is the patient under 18? *

No - I am an adult completing this myself

Yes - I am a parent / guardian completing this

If under 18, a parent/guardian co-signature section will appear at the end of this form.

Fields marked * are required

Step 2 of 5

Assessment & clinical consent

Your agreement to proceed with the neurodevelopmental assessment and how it will be conducted

📋Items marked Required must be accepted to proceed. Optional items are entirely your choice — declining will not affect the care you receive.

🧠

Neurodevelopmental assessment Required

I agree to take part in a neurodevelopmental assessment (ADHD and/or autism) carried out by Crystal Pathways clinicians.

The assessment may include structured clinical interviews, standardised questionnaires, cognitive tasks, and direct observation across one or more sessions. It may also require input from people who know you well.

You may withdraw from the assessment at any time without giving a reason. This will not affect your access to other services. Clinical governance follows NICE CG142 (Autism) and NG87 (ADHD).

💻

Remote / video consultation Required

I understand that some or all of my assessment may be conducted via secure video call.

Video consultations are conducted via a secure, encrypted platform in line with NHS Digital and UK GDPR standards. Participate from a private location where you feel comfortable.

If you experience technical difficulties or prefer a different format, please let your clinician know and we will make reasonable adjustments.

🎙

Recording of sessions Optional

I agree that my sessions may be recorded for clinical accuracy and quality assurance purposes.

Recordings are stored securely, accessed only by your clinical team, and used solely to ensure the accuracy of clinical notes. They are not shared outside your clinical team without separate consent.

Recordings are retained for the duration of your active case only. You may withdraw this consent at any time.

Step 3 of 5

Data & information sharing

How your information is used, shared, and stored — including with your referrer, employer, and third parties

🏢

Sharing with referrer / employer Required

I agree that relevant assessment information may be shared with the organisation that referred me.

Where you have been referred by an employer, occupational health service, or another organisation, Crystal Pathways will share the outcome of your assessment with that referrer. This typically includes a written report summarising findings and recommendations.

We will not share information beyond what is clinically necessary. You will receive a copy of any report shared. You can request a copy of all information held about you under UK GDPR Article 15.

📄

Written assessment report Required

I understand a written report will be produced and shared with me and, where applicable, my referrer.

Following your assessment, a written report will be produced by your clinical team and signed off by our Consultant Psychiatrist. This report will include background history, clinical observations, assessment findings, diagnostic conclusions, and recommendations.

You will always receive a copy. If referred by a third party, a copy will also be sent to them unless you withdraw this consent before the report is finalised.

👥

Third party information gathering Optional

I agree that the clinical team may contact relevant third parties (e.g. GP, school, employer) to gather additional information to support my assessment.

Additional information from people who know you in different contexts can significantly improve the accuracy of a neurodevelopmental assessment. This may include contacting your GP, a teacher or SENCO, or a line manager.

We will always tell you who we are contacting and why before doing so. You may limit or withdraw this consent for specific individuals at any time.

🔬

Anonymised research & service improvement Optional

I agree that anonymised data from my assessment may be used to improve services and contribute to neurodevelopmental research.

With your permission, anonymised and de-identified information from your assessment may be used to support service evaluation, audit, and research. No personally identifiable information will ever be shared for these purposes.

This is entirely optional. Declining will have no impact whatsoever on your assessment or care.

📷

Photography & observation records Optional

I agree that clinical observations, including still images where clinically relevant, may be recorded as part of my assessment record.

In some assessments, clinical teams may make observational notes or still images to support the clinical record. These are stored securely within your clinical file and accessed only by your treating team.

Images or observational records are never used for marketing or training without your separate written consent.

Step 4 of 5

Use of AI-assisted tools

Crystal Pathways uses a registered AI medical device to assist with clinical documentation during your assessment

⚠Tortus is a UKCA-registered AI medical device. Its use requires your explicit consent. Declining will not affect the quality of your assessment — your clinician will document manually.

🤖

Tortus AI clinical documentation assistant Optional

I agree to the use of Tortus, a registered AI medical device, to assist with clinical documentation during my assessment.

What is Tortus? Tortus is a registered AI medical device that assists clinicians with real-time documentation during clinical consultations. It generates structured clinical notes, allowing your clinician to focus on you rather than on note-taking.

What data does it process? Audio from your consultation is processed to generate clinical notes. Audio is not retained after note generation. All notes are reviewed, edited, and approved by your clinician before being added to your record.

Regulatory status: Tortus is a UKCA-registered AI medical device operating under the UK Medical Devices Regulations 2002. Data is processed in accordance with UK GDPR and the Data Protection Act 2018.

Your choice: Declining will have no impact on your assessment or care. Your clinician will take notes manually if you prefer.

Step 5 of 5

Declaration & signature

Please sign below to confirm your consent choices. Both a drawn and typed signature are required.

✓By signing, you confirm that you have read and understood this consent form, that your choices reflect your genuine wishes, and that you are signing freely and without pressure.

Patient signature

Full name (typed to confirm identity) *

Draw your signature Clear

Use your mouse, stylus, or finger to sign above.

Date *

Parent / Guardian co-signature

As the patient is under 18, a parent or guardian must also sign. Please complete your details and signature below.

Guardian full name *

Relationship to patient *

Guardian email *

Guardian phone

Guardian typed name *

Guardian drawn signature Clear

⚠Please complete all required fields.

✓

Consent recorded

CP-CONSENT-0000

Your consent form has been received and securely stored by the Crystal Pathways clinical team. A copy of your choices will be held in your clinical record.

If you wish to withdraw or amend any consent item at any time, please contact your clinical team directly.

Reference: · Your consent choices can be amended at any time by contacting Crystal Pathways.

Crystal Pathways · Brighton Health Clinic

Neurodevelopmental Assessment — Consent Record

Reference