Parent Consultation Intake & Consent Form

Date

Parent/Guardian Name:

First NameLast Name

Relationship to Child:

Child’s Full Name:

First NameLast Name

Child’s Date of Birth:

Child Age:

Check what apply

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Preferred Method of Contact:

Is your child a previous client of Sensory Street?

If NO, how did you hear about our service?

Please briefly describe the concerns you have about your child and what you hope to gain from the consultation:

Areas of Concern (Check all that apply)

Other

Consent to Consultation
I understand that the consultation services provided by Dr. Beatrice C. Hector are educational and supportive in nature and are not occupational therapy treatment. I acknowledge that no diagnosis will be provided, and no therapy relationship is established as part of this service. I understand that the purpose of the consultation is to receive general guidance and strategies that I may choose to implement. I also understand that all shared information will remain confidential, and I have the right to request a written summary of recommendations. By signing below, I give consent for myself and my child to participate in this consultation service.

Parent/Guardian Signature:

Date

Parent Consultation Intake & Consent Form

Parent and Child Information

Reason for Consultation