Safeguarding Consent for Treatment

Two lit pink candles, a small purple figurine, two glass cups of herbal tea with lavender and thyme, a wooden tray, and a vase with purple flowers on a wooden surface.

Please fill in this form to give consent for a child who is under 18 to receive a one to one treatment session - thank you

Client's Name

The name of the under 18 year old who will receive the one on one session

First Name

Last Name

Date of Birth

MM

DD

YYYY

Parent / Guardian's Name

First Name

Last Name

Parent / Guardian's Contact number

(###)

###

####

Date of retreat : planned session

MM

DD

YYYY

Consent for Treatment

Consent for Treatment I, the undersigned, hereby give my consent for my child to participate in one-to-one treatment sessions with a trained therapist. I understand that these sessions are designed to provide support and guidance to my child and may involve the sharing of confidential information. Confidentiality and Safeguarding I acknowledge that during the course of treatment, my child may disclose sensitive information. The therapist is committed to maintaining confidentiality in accordance with professional standards and UK law. However, I understand that if any information of a concerning nature is disclosed, which suggests that my child or others may be at risk of harm, the therapist is obligated to refer this information to the relevant authorities or professionals to ensure appropriate safeguarding measures are taken. Professional Responsibilities The therapist will exercise their professional judgment in determining when it is necessary to breach confidentiality for safeguarding purposes. This may include, but is not limited to, contacting social services, law enforcement, or other relevant agencies. Acknowledgment and Consent I have read and understood the information provided in this consent form. I consent to my child's participation in the treatment sessions and acknowledge the therapist's responsibilities regarding confidentiality and safeguarding.

Please write your name here to indicate that you give your consent to the above

Safeguarding Consent for Treatment

Health Yourself