Wellbeing Counselling Consent

Counselling Parents & Carers Consent Form

All parents must complete the parental consent form and counselling contract for children/young person’s partaking in the service, before counselling can commence, thank you.

By completing the form you declare you have read and agree to our confidentiality statement and disclosure guidance.

If you have any questions, concerns or need support completing online forms and bookings please call the Care Team on 01702 552 200.

Young person's name*
First Last
Young person's email address
Date of birth*
DD slash MM slash YYYY
Phone*
Address*
Street Address Address Line 2 City Postal code
Parent/guardian details:
Name*
First Last
Email
Address*
Street Address Address Line 2 City Postal code
Phone
Emergency Contact Number*
Consent
I have read and understood the information given to me regarding the services Havens Hospices Counselling provides. I understand that if I have further enquiries, I can discuss them with the staff. I understand that while the young person named above is working with Havens Hospices Counselling, he/she will be subject to the service’s code and conduct of behaviour and will be required to conform with the instructions and guidance of the service. If you agree that the named young person above should participate in Havens Hospices counselling services, please sign below. Thank you.
Parent/carer full name - this will be used as your electronic signature*
Consent*
I agree that my full name in the field above will be used as my electronic signature
Date*
DD slash MM slash YYYY

Parents/Carers Consent for children's counselling

Counselling Parents & Carers Consent Form

Parent/guardian details:

Consent