Consent form for children

Child Therapy Consent Form

Child's details

Child's Name:

Child's Date of Birth:

Parent/Guardian(s) details

Parent/Guardian(s) Name:*

Address:

Phone Number:

Email Address:

Emergency Contact

Emergency Contact Name:

Relationship to Child

Phone Number:

Alternative Phone Number:

Therapist details

Therapist Name:

Therapist Phone Number

Practice/Clinic:

Purpose of Therapy

The purpose of therapy is to provide psychological support, including assessment, treatment, and advice to help your child manage emotional, behavioural, or developmental concerns.

Confidentiality

Information shared in therapy is confidential and will not be released without your consent, except in cases required by law, including:

Risk of harm to the child or others
Suspected abuse or neglect
Court order

Therapists may share relevant information with parents/guardians to support treatment while respecting the child’s privacy.

Consent to Share Information

I give consent for the therapist to share information about my child’s therapy with the following individuals or organizations as needed for my child’s care:

General Practitioner (GP):

Yes

No

School/Teachers:

Yes

No

Other Professionals (e.g., educational psychologist, psychiatrist, occupational therapist)

Yes

No

Please list any specific individuals or organizations to share information with:

_{This consent is voluntary and can be withdrawn at any time by providing written notice.}

Consent to Video/Audio Record Sessions

I understand that therapy sessions may be recorded for the following purposes:

Clinical review and supervision
Training and professional development
Therapeutic review and progress tracking

I give consent for the therapist to video/audio record my therapy sessions:

Yes

No

I understand that:

Recordings will be kept confidential and stored securely.
Recordings will not be shared outside the agreed-upon purpose without additional consent.
I may withdraw consent at any time, and future sessions will not be recorded.

Voluntary Participation

Participation in therapy is voluntary. You may withdraw consent at any time. Therapy may also be ended if it is determined it is no longer in your best interest.

Risks and Benefits

Benefits may include improved coping skills, emotional regulation, communication, and relationships.

Risks may include experiencing uncomfortable emotions, discussing difficult topics, or temporary stress as issues are explored.

Parent/Guardian Involvement

Parents/guardians may be involved in sessions as appropriate, particularly for children under 12. The therapist will work with both the child and parent(s)/guardian(s) to determine the level of involvement.

Video conference (if applicable)

Sessions may be conducted via secure video or phone. Confidentiality measures will be in place, but there are inherent risks in electronic communication.

Consent for Treatment

I, the undersigned, am the parent/legal guardian of the child named above. I have read and understand the information provided in this consent form. I consent to my child receiving psychological services from the therapist named above.

I understand that:

Therapy is a collaborative process and outcomes are not guaranteed.
I may ask questions at any time.
I may withdraw consent at any time.

Keeping of Records

Please note that this information will be held in accordance with the principles of the GDPR alongside the professional guidelines of the British Psychological Society (BPS) and the Health Care Professional Council (HCPC).

Parent/Guardian(s) Signature:

Date signed:

Child Signature (if appropriate)

Date signed:

Therapist Signature:

Date signed: