€950,00 EUR

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Child's Name

Child's Date of Birth

Child's Gender

Child's Address (if different from your own)

What class is your child in? (Up an update on education)

What is your main concern for your child at the moment?

2nd Parent's Name:

2nd Parent's Phone Number

2nd Parent's Email

In the case of separated parents, I confirm that both parents consent to this appointment.YESNOThis is complicated - I will email you to explain on [email protected]

I give consent for myself and/or my child to participate in healthcare services as appropriate with EPT Clinic. I understand that this involves giving consent for personal and sensitive data to be held and used as described in EPT Clinic's GDPR policy.I consent

If I visit in person (e.g. for an assessment), I give consent for EPT Clinic to take a photo of my child for their file. This will help EPT to remember the child's face if you contact us in the future.YES NO

I give consent for the content for my feedback from evaluation questionnaires, and other feedback which I provide to be used for research, training and improvement purposes.YESNO

I give consent that EPT therapists liaise with other professionals (e.g. OT/GP) involved in the child's life as appropriate and in consultation with me.YESNO

I understand that EPT Clinic is a recognised training clinic and as such, trainee professionals and students are part of our team.I understand

Do you anticipate that you will require documentation for court proceedings or any legal involvement?YESNO

Have you have attended EPT (remotely or in person) before?YesNo

Is there anything else you wish us to know?

Signiture:

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Educational Psychology Assessment

This assessment explores a young person's thinking and learning preferences and needs. Includes a comprehensive psychology report.

What you'll get:

A comprehensive evaluation of thinking and learning abilities and needs.
Clarity on whether the young person is dyslexic, or presenting with a general learning difficulty (e.g. an intellectual disability).

Please see EPT terms and conditions.