Behavioural Support Form

Name(s):

Email:

Phone number:

Postcode/borough:

Child's name:

Child's date of birth:

Does your child have any medical issues:

Does your child have any SEN or a diagnosis?

If other, please provide more information here...

Siblings:

Other significant people in the household:

Significant life events (including bereavement/loss):

Any other relevant family information:

What behavioural concerns would you like support with?

How long have they been a concern?

Are there times when your child's behaviour is worse? If so, when?

Usual causes (situations/triggers)?

Can you describe what the behaviour looks like?

How do you usually respond?

Is your response always the same or does it vary?

Are there times you find it harder to manage? If so, when?

Do different people in your family home have different responses?

What have you tried already?

What would you like to achieve from the session?

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

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

I am aware that Rebecca 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 Rebecca 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