Child Therapy Consent Form

This is a consent form for child psychotherapy, also known as play therapy. This type of psychotherapy encompasses using play, for children between the age of 3 and 12 years old. Caregivers and/parents are to read this form and complete it accordingly. This form needs to be filled in to indicate that you are willingly committing your child to psychotherapy at Revelations Quest Psychology (RQ Psych). Please complete it and submit it, as psychotherapy cannot commence before it is submitted and received.

Minor’s Details:

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Thank you for your response. ✨

As the above-said minor’s caregiver(s)/parent(s), to be mentioned below, I/we, hereby voluntarily give consent to:

My/Our child receiving psychological services (including screenings, assessments, psychotherapy, etc.)
The discussion of my/our child’s clinical information by a multi-professional team where need be. All patients’/clients’ rights are protected in terms of the regulations set by the Health Professions Council of South Africa (HPCSA).
My/Our child undergoing any necessary psychometrics tests and treatment advised and explained to me/us
and/or them.
Reports being obtained by other authorised and appropriate sources (e.g. school, GP, psychiatrist, court of law, etc.).
A relevant psychological report about my/our child being submitted to institutions as authorised by me/us.

NOTE: Reports used for forensic investigations, custody proceedings and other legal proceedings will not be provided by the treating psychologist. If such services are required, the client(s) is encouraged to seek professional help from another psychologist in that regard.

I/We understand that all communication and all records relating to the provision of the psychological services to my/our child are confidential, but there are limitations to confidentiality as explained to me, us and/or my/our child. I acknowledge that I/we had the opportunity to carefully read this document, to ask questions, or communicate concerns arising from it. I/We further acknowledge that I/we have read and understand the information contained in this document, and that I/we give consent willingly on the following date:

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Caregiver/Parent Details:

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Caregiver/Parent Name and Surname

Date of Birth (YYYY-MM-DD)

Phone Number

Email Address

Relationship to Minor

Caregiver/Parent 2 Name and Surname

Date of Birth (YYYY-MM-DD)

Phone Number

Email Address

Relationship to Minor

If 1 parent/caregiver is available to give consent, please provide reason:

Preferred Way To Receive Feedback

✨ That’s it! Send it over and we’ll take care of the rest.

Personal Responsible for Account:

By providing the information below, you acknowledge that the individual is aware of such responsibility, and gave you consent to make such information available.

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Full Names and Surname

Date of Birth (YYYY-MM-DD)

Identity Number/Passport Number

Relationship to Client (i.e. Parent, Sister, Aunt, Partner, etc.).

Occupation

Home Language

Email Address

Phone Number

Medical Aid Details:

By providing this information, you are consenting for the treating psychologist to claim for sessions from your medical aid scheme.

Medical Aid Scheme

Main Member’s Name and Surname (00)

Main Member’s Relationship to Client (i.e. Spouse, Child, Parent, etc.).

Membership Number

Client’s Dependent Number (i.e. 01, 02, 03, etc.).

Home Address

Emergency Contact Details:

In the event of an emergency, such as when one is a danger (physically/emotionally) to themselves or other(s), the clinician is legally obligated to warm the person in danger, and/or in a position to contact a 3rd party to help mitigate danger to self and/or other(s) (e.g. emergency services, trusted individual/next if kin, authorities, etc.).

This is a trusted individual that can be contacted in the event of an emergency. By providing this information below, you acknowledge that the individual is aware of such responsibility, and gave you consent to make such information available.

Full Names and Surname

Date of Birth (YYYY-MM-DD)

Relationship to Client (i.e. Cousin, Partner, Sibling, etc.).

Home Language

Phone Number

Home Address/City