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Child Therapy Consent Form Submission
Hi Valued Client, Thank you for submitting the informed consent form for child therapy. The journey begins!
Adult Name & Surname
(required)
Date of Birth
(required)
YYYY-MM-DD
Phone Number
(required)
Email Address
(required)
Relationship to Client
(required)
Select One Option
Mother
Father
Legal Gaurdian
Other
Other Parents’ Details
(Names, Contact Details, Did they give their consent as a parent?, etc.) (required)
Child Details:
Child’s Name and Surname
(required)
Date of Birth
(required)
YYYY-MM-DD
Child’s Identity Number
(required)
Child Gender
(required)
Select One Option
Male
Female
Background
Has your child been to psychotherapy before
Yes
No
Reason for Seeking Therapy for Child
Relevant Medical/Developmental History
Medical Aid Details:
Medical Aid Scheme
(if applicable, if not applicable state “N/A” through out) (required)
Membership Plan/Option
(required)
Membership Number
(required)
Dependent Number
(i.e. 01,02,03,etc.) (required)
Main Member’s Details
(i.e. Names, ID Numbers, etc.) (required)
Main Member’s Relationship to Client
(i.e. Parent, Aunt, Grandparent, Legal Guardian, etc.) (required)
Address
(required)
By submitting this information and form, you are willingly consenting to a consultation at RQ Psych for your child, and giving RQ Psych permission to contact you when need be. Please read terms below: 1. Confidentiality – All information disclosed within consultations is confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law (e.g., threat of harm to self or others, abuse of a child or vulnerable adult, etc.). 2. Cancellation Policy – Please provide at least 24 hours notice if you need to cancel or reschedule an appointment. Late cancellations or missed sessions without notice may be subject to the full session fee/ at least 50%. 3. Consent to Treatment – By clicking submit below, you agree to your child participating in a psychological consultation, (including psychotherapy sessions, screenings, assessments, etc.) and understand that you have the right to raise questions or terminate therapy at any time. NOTE: No psycho-legal/medico-legeal reports will be written/provided by the treating psychologist. If such services are required, the client/patient is encouraged to seek professional help from another psychologist in that regard
Submit
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