RPPS Consent Form -

Therapy Consent Form - Pratima RPPS

Child's name

Child's date of birth

Child's home address

Name of parent(s) / carer(s)

Parent(s) / carer(s) email and telephone contact details

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

I give consent for my child to attend sessions with Pratima Patel, located at Ravenscourt Park Preparatory School, 16 Ravenscourt Avenue, London, W6 0SL

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

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

I confirm that I have provided all necessary medical information regarding my child to Pratima Patel including any specific medical requirements

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

All sessions, including the review session on week 12 are £70. 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

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. If you wish to cancel a session, we please ask for 48 hours notice, otherwise the full fee will be payable. To cancel your child's session, please email pratima@childrenswellnesscentre.co.uk

If a session is cancelled with more than 48 hours notice, and you have already paid for this session, this fee will be taken off your next monthly invoice, or refunded back to you if you do not continue sessions into the next month

Sessions will only be provided during the school term dates, meaning you will not be charged for any sessions that fall on an inset day, or school holiday

Should the Therapist need to cancel a session, 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

2 weeks notice is required if you decide to terminate your sessions so the Therapist can prepare ending work for your child

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

Counselling Medical and Consent Form

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