test-form -

Therapy Consent Form - Taylor

Child's name

Child's date of birth

Name of school

Child's home address

Parent/Carer telephone contact details

Emergency local contact 1 (other than parent/carer)

Emergency local contact 2 (other than parent/carer)

Child's Doctor and Medical Practice address and telephone number

Child's allergies (if known)

Please list any medication that your child is taking

Please list any additional important medical history

The Therapist that you are seeing is DBS checked and holds Professional Indemnity insurance, practicing within the ethical framework of their profession and their British Association of Counselling and Psychotherapy registration. Any information shared by the client with the Therapist and The Children's Wellness Centre is treated as confidential, unless a safeguarding concern is disclosed. Client details will not be passed onto other parties unless specifically requested e.g. forwarding information to other professionals and schools

I give consent for my child to attend sessions with Taylor Sam-Green, located at The Children’s Wellness Centre, 27A Fishers Lane, Chiswick, W4 1RX

I give full consent, in case of an emergency, for Taylor Sam-Green to authorize any medical treatment deemed necessary for my child either on the premises of The Children’s Wellness Centre, or in a hospital

I have read the information document shared with me and am aware of the processes and procedures relating to the sessions

I am aware that all notes and paperwork are owned and securely stored by my child's individual Therapist

I confirm that I have provided all necessary medical information regarding my child to Taylor Sam-Green including any specific medical requirements

If age-appropriate, I give consent for my child at times to arrive for their session unaccompanied and travel home on their own after

Yes

Payment Terms and Conditions. Please tick each box in acknowledgement of our policies and procedures

All sessions are £80. The Children’s Wellness Centre will send an email invoice at the start of each month and sessions are payable via BACS on an advanced monthly basis. If your child begins sessions part-way through a month, you will receive an invoice for the remaining monthly sessions

If you have any difficulties in paying this, please email therapy@childrenswellnesscentre.co.uk and we can support you with a payment plan

If you would prefer to pay by cash, please bring this in a sealed envelope, with your invoice reference number on and give this to your Therapist

It is very important for the progress of the work, for children to attend weekly, consistent sessions. Having breaks and absences can really affect the progress, so where possible please support your child in coming each week. Of course we understand that there are going to be odd occasions when a session may be missed. We can accommodate one missed session every 12 weeks at no charge, in line with the Absence Policy, sent to you prior to starting sessions. This one missed session can be cancelled at any time and no fee will be payable. If you have already paid for the session in advance, this will be taken off your following invoice. If your child does not continue sessions into the following month, this will be refunded back to you

Due to very high demand for our Therapeutic services, any further missed sessions due to client cancellations (beyond the one accommodated missed session every 12 weeks) will have to be charged in full

If your child's session falls on a public holiday, this session can be cancelled at your discretion and will not be included as your one accommodated missed session. Between the 1st July and 31st August each year we can accommodate 2 missed sessions at no charge

Should the Therapist be unable to make a session, an additional session will be first offered. If this session has already been paid for, this fee will be taken off your invoice the following month, or refunded back to you if you do not continue sessions into the next month. Any cancelled sessions by the Therapist are not included as your one accommodated missed session

2 weeks notice is required if you decide to terminate your sessions at any point

If the client has a complaint against the Therapist that they are seeing, they must inform The Children’s Wellness Centre, emailing jake@childrenswellnesscentre.co.uk immediately and all efforts will be made to resolve and settle any disputes, without litigation

Therapy Consent Form - Taylor Sam-Green

Sign up to our newsletter for the latest news and events...

Ready to find out more?

Contact & Location

Follow Us

Quick Links

Our Charity Support