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Barnet, Enfield and Haringey



                                                                                      Mental Health NHS trust
                                                                                   A University Teaching Trust





































































           I agree to my personal information being seen by those staff involved in my care. I agree that if the Trust removes my name and address,
           they can use this information to monitor how well it is treating people from different backgrounds.











          CONFIDENTIAL ONCE COMPLETED                                           19/10/2015 Haringey Clinical Division
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