Consent for Assessment and Therapy

Please read this form carefully. It explains the care we offer and asks for your permission to assess your child and provide therapy. Ask us about anything that is unclear before you sign. You can withdraw your consent at any time. Fields marked * are required.

1. About your child

Child’s full name *Name your child likes to use (optional)Date of birth *School or nursery (optional)

2. Parent or legal guardian

Your full name *Relationship to the child *Phone number *Email address *Emergency contact name (someone other than you) *Emergency contact phone number *

3. Services you consent to

Tick every service you give consent for. If we later recommend a service that is not ticked here, we will explain it and ask for your consent first.

Other service (please describe) (optional)

4. What assessment and therapy involve

Assessment: We get to know your child through play, observation, conversations with you and, where suitable, standardised assessment tools. We explain what we find and agree goals with you.
Therapy sessions: Sessions are play-based and follow your child’s interests. Depending on the service, they may include movement and sensory activities, hands-on guidance (for example, helping your child hold a pencil or position their body), communication and mouth-movement activities, and practising everyday routines. Your therapist will explain activities before they start.
Home and school activities: We may suggest activities to practise between sessions. Every child progresses at their own pace, and we cannot guarantee particular results.
Benefits and risks: Therapy aims to support your child’s development, independence and participation in daily life. Risks are usually low. Your child may feel tired, frustrated or uncomfortable during some activities, especially new sensory experiences. We watch closely, offer breaks and stop any activity that causes distress.
Your child’s voice: We explain activities in a way your child can understand and respect their signs of discomfort or refusal. If your child is unhappy with part of their therapy, we will talk with you about it.
Your role: Please share information relevant to your child’s care, including changes in health or medication. A parent, guardian or adult you have authorised should stay at the centre during sessions unless we agree otherwise, and collect your child on time.
Online sessions: Some sessions, reviews or parent coaching may take place by video call if you agree below. We use a secure platform, and an adult should be present with your child.

5. Confidentiality and records

We keep your child’s records confidential and store them securely, in line with Kenya’s Data Protection Act, 2019 and our privacy policy.
Only the clinicians and authorised staff involved in your child’s care can see their records. We may discuss your child’s care in confidential clinical supervision to maintain quality.
We will not share information with a school, doctor or other provider without your permission, except where the law requires or allows it. For example, if we believe a child is at risk of harm, we must report it to the relevant authorities under the Children Act, 2022, and we must comply with a court order.
You may ask to see or correct your child’s records by contacting the centre.

6. Optional permissions

These permissions are separate and optional. Saying no will not affect your child’s care. We never use your child’s photos, videos or story for marketing or social media without separate written consent.

Share relevant information with my child’s school or nursery to support their goals *

Share relevant information with my child’s doctor or other health providers *

Take photos or video of sessions for clinical records, progress tracking and supervision only (never published) *

Provide online (video call) sessions when suitable *

Names of the school, doctor or providers we may contact (optional)

7. Health and safety

Allergies, medical conditions, medicines or safety needs we should know about (optional)

8. Declaration

Please tick each statement to confirm it.

9. Sign this form

Parent or legal guardian: type your full name exactly as entered above.

Your full name as your signature *

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