Annual School Consent & Medical Form

- Today's Date*
  
  DayMonthYear
  Date
- Name of the Child*
  
  First NameLast Name
- Child's Date of Birth*
  
  DayMonthYear
  Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  City
  
  Postal / Zip Code
- Address
- Child's School*
- School Site (if Applicable)
- Child's Class
- Asian, Asian British, Asian WelshBlack, Black British, Black Welsh, Caribbean or AfricanMixed or MultipleWhiteOther
- Please specify further if you wish
- BuddhistChristianHinduJewishMuslimSikhNo religionOther
- Please tell us the child's home or living circumstances (such as who they live with)
- Please list your child's medical needs, diagnoses and any medication they are taking. If not relevant, please state 'None'*
  Please include diagnoses such as Epilepsy, Learning Difficulties, Visual Problems, Syndromes
- Please list any allergies and any medication required. If not relevant, please state 'None'*
- Please list any reasons that the child cannot participate in some parts of therapy, play, or physical movement ('contraindications'). This might include Visual Impairments, fractured/ broken bones, physical difficulties, injuries including spinal injuries, heart or breathing problems, detaching retina. If not relevant, please state 'None'*
- I understand the purpose of Occupational Therapy Input for my childI consent to Occupational Therapy Assessment for my childI consent to Occupational Therapy Intervention and/or Consultation for my child
- Please specify if there are any Safeguarding or Child Protection concerns, investigations or support at present
- School/ Education Professionals involved in my child's careHealth and Social Care Professionals involved in my child's careOther
- Please state anyone you do NOT consent for information about your child being shared with:*
- We take photos and videos during our assessment and intervention therapy sessions, to help us understand each child's needs, to share recommendations (with parents and school staff), to provide learning opportunities, and to evidence outcomes.
  
  We teach courses for Juniper Tree Therapy and Sensory Attachment Intervention, and ask for permission to share video footage and photos to help other professionals understand how therapy might work.
- I agree to photographic, audio and video recordings of myself and/or the child as part of assessment and/or interventionI agree to anonymised data about myself and/ or the child be used for research purposesI agree to video recordings of myself and/ or the child being shown to supervisors for the purposes of accreditation and supervisionI agree to photos of myself and/ or the child being shown to other professionals involved to inform planning for future support.I consent to photographs being used on the Juniper Tree Therapy website and social media pages (Instagram, Facebook, and Twitter), with the child’s face blurred or covered to ensure their privacy is maintained.I agree for video footage of myself and/ or the child to be shown in Juniper Tree Therapy or Sensory Attachment Intervention Professional training coursesI do not consent to any recordings and would like to speak to a Therapist to understand why this is required
- YesNo
- Yes - I consent to therapy assessment and intervention. If my circumstances change, I will contact the Occupational Therapist to withdraw consent, by emailing hello@junipertreetherapy.com, by telephone, or by updating this formNo - I do not consent to any direct therapeutic contact
- Yes
- Any other relevant comments
- My Name:*
  
  First NameLast Name
- My Email:
  example@example.com
- My Phone Number:*
  
  Area CodePhone Number
- My Phone Number
  Preferably mobile
- Relationship to the child:*
- Signature (Click or tap in the box to sign)*
  
  Clear
- YesNo
- If you are completing the form on the behalf of the person with PPR please state your name:
  Your full name and position/ relationship. E.g. Emma Shedlow, Occupational Therapist
- Should be Empty: