Neurodevelopmental Coaching Sessions: Child Sessions -

Neurodevelopmental Coaching Sessions: Child Sessions

Contact

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Parent(s) / carer(s) names

Parent(s) / carer(s) email address

Parent(s) / carer(s) contact number

Parent(s) / carer(s) home address

Child’s first name

Any preferred name

Child’s gender

Child’s date of birth

Please list who holds parental responsibility for the child?

Does your child have any confirmed diagnoses?

About Your Child

Please share three words that describe your child:

What does your child really enjoy?

What things are hardest for your child right now?

How does your child usually let you know if they’re happy, upset, or need help?

Are there any sounds, textures, smells, or sights your child finds tricky?

About Your Family & Supports

Who lives at home with your child?

Where does your child spend most of their week? (e.g., school, home education etc.)

Are there any other professionals helping your child right now?

Anything important about your family’s culture, routines, or beliefs that our coach should know?

Your Priorities

What made you want to start this coaching?

What would you most like to see change or improve?

How confident do you feel about supporting your child’s needs right now?

Not confident

A little

Fairly

Quite

Very confident

How is your child’s overall wellbeing at the moment?

Not doing well

A little low

Okay

Good

Excellent

Please share anything else you would like our coach to know before the first session?

Medical Consent and Drop-Off Agreement

As the sessions are provided in-person, please list any medical conditions, allergies, or medications your child is currently taking:

Child’s doctor and medical practice address and telephone number:

I, the undersigned parent/legal carer, hereby consent to leave my child under the care and supervision of Caroline Barber

I confirm that my child is in suitable health to participate and that I have informed Caroline Barber of any relevant medical conditions, allergies, or medications

In the event of a medical emergency, I authorise Caroline Barber and The Children’s Wellness Centre to seek necessary medical treatment for my child, including calling emergency services if required. I understand that I will be contacted as soon as possible in such circumstances

Parent/carer Name

Signature

Sign Here

I consent for my child to travel to and from their coaching session independently

Yes, I consent

No, I do not consent

N/A

Parent/carer Name

Signature

Sign Here

In the event that I cannot be reached, I authorise the following emergency contact to be contacted on my behalf. I confirm that I have obtained their consent to share their contact information.

Please tick the following informed consent statement and cancellation statements.

Attendance Consent – I give consent for my child to attend in-person neurodiversity coaching sessions with Caroline Barber, located at The Children’s Wellness Centre, 27A Fisher’s Lane, Chiswick, W4 1RX

Nature of Service – I understand that this session is for child neurodiversity coaching purposes only and does not constitute therapy, counselling, medical advice, or any other regulated mental health service

Confidentiality – I understand that information shared in the session is confidential, except where there is a legal obligation to disclose or where there is a risk of harm to myself, others, or a child’s safety

Recording & Note-Taking – I understand that the session will not be audio or video recorded. I acknowledge that the coach may take written notes for professional purposes, which will be securely stored in compliance with privacy laws. I accept that these notes remain the property of the coach

Data Protection – I consent to my personal data being collected, processed, and stored in compliance with applicable data protection laws, and I understand how my data will be used as explained in the privacy notice

Fees & Payment – I agree to pay the full fee for this session as stated at the time of booking. I understand that any cancellation or rescheduling of any session must be made at least 48 hours before the appointment. Cancellations with less than 48 hours’ notice, or failure to attend the session without notice, will result in the full fee being charged

Follow-up parent work:

In some cases, you may decide to arrange additional online follow-up parent sessions with Caroline.

Purpose & Scope of Service – I understand that these sessions are designed to provide information and strategies relating to parenting and does not guarantee specific outcomes

Disclaimer – I acknowledge that all information provided is for educational purposes and that I am solely responsible for decisions and actions I take in relation to my parenting

Use of Online Platform – I consent to using the agreed video conferencing platform for this session and understand that, while reasonable steps are taken to ensure privacy, no online communication can be guaranteed 100% secure

Technology Issues – I understand that technical issues may occur and that, if the session is disrupted, the coach will make reasonable efforts to reschedule or complete the session but is not responsible for technical failures outside their control