SEN Form -

SEN Form - LONDON

Name(s):

Email:

Phone number:

Postcode/borough:

Child's name:

Child's date of birth:

Does your child have any SEN or a diagnosis?

Does your child have an EHCP?

Yes

Does your child have any medical issues:

Siblings:

Significant life events (including bereavement/loss):

Any other relevant family information:

Brief summary of support needed:

Parental Consent and Agreement

I am aware that in some situations Fiona may need to talk to other members of The Children’s Wellness Therapy team regarding information disclosed in the session

Unless Fiona needs to share details with The Children’s Wellness Centre Therapy team, I am aware that all other information shared between myself and Fiona will remain confidential, except where a safeguarding concern is disclosed

I am aware that Fiona will adopt a client-led approach and will offer advice, support and options for next steps, but it is my responsibility to decide what is right for my child

I am aware that payment for each session is due in advance and I will be sent an email invoice for this

I am aware that should I need to cancel my session I need to give 24 hours’ notice, either by emailing Fiona directly or the main desk at The Children’s Wellness Centre

I am aware that failure to give the sufficient notice of cancellation, will mean the full fee is still due

Family Support Pre-Consultation Form

Parental Consent and Agreement

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