€500,00 EUR

Child's Name

Child's Date of Birth

Child's Gender

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

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

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

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

Is there anything else you wish us to know?

Signiture:

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Psychotherapy Package of 5 Sessions

Book psychotherapy with Laura Dennehy, Senior Psychotherapist. Sessions are 50 minutes each and can be in person or online.

By booking ahead, you can secure future dates and times that will suit you and your family.