Parent Consent Form - Inspire Wellbeing Services

Parent/Carer Consent Form

Parent consent form (for child or young person)

Contact details

Helping us get in touch with you easily and securely.

Why is this important?
We need basic contact details to communicate with you, send important information, and ensure you feel supported from the start.

Tip: If you prefer certain contact methods (e.g., email over phone calls), let us know.

First Name of client

Last Name of client

Phone/Mobile

Preferred email address

Address

Address Line 1

Address Line 2

City

Post code

Country

Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe

Can we contact you by (select all that apply):

Telephone

When is the best time to contact you?

Giving your consent

Understanding your rights and privacy.

Why is this important?
Your privacy is a priority. We use your information only to support your wellbeing and ensure you receive the right support.

Tip: If you have any concerns about confidentiality, feel free to ask—we are happy to discuss.

To work with you we must have your consent. Without it, your case will be closed. In consenting, you are giving permission for sessions to commence with our therapist(s) either face to face at one of our agreed locations, or online according to the terms below. Consent can be revoked at any time, but depending on the type of consent revoked, this may result in the termination of our service to you.

Please read the following information carefully, select your preferences and then sign and date the form. If you have any concerns, please discuss them with Inspire Wellbeing Services.  You can note any limits/restrictions if appropriate.

I consent to my child(ren) receiving support from Inspire Wellbeing Services

Yes

I consent to receiving parental support from Inspire Wellbeing Services

Yes

I consent to the content of this form and my personal data being stored on Inspire Wellbeing Services/ Kids Inspire’s internal database in line with data protection law. I understand that Inspire Wellbeing Services may also use the information to help evidence the effectiveness of the service during and after the support.

Yes

I understand that Inspire Wellbeing Services is a private community interest company with Kids Inspire being the sole shareholder and beneficiary of all profits. When appropriate, personal data (including the details submitted on this form) can be shared between both entities in both directions. 

Yes

I understand that I have the right to restrict what information may be shared and with whom. 

Yes

I understand that I may withdraw my consent to share information at any time but that might result in a reduction of services being available.

Yes

I agree that personal data relating to me/ my family which has been or is obtained by Inspire Wellbeing Services, including personal data given by me on this form may be held and processed either on digital or manual records.  

Yes

I give my permission to the storage and processing of sensitive personal information by Inspire Wellbeing Services.

Yes

I give permission for the sessions to be recorded for quality assessment purposes. Please note at the end of the therapy all recordings will be destroyed in accordance with our Data Retention guidelines. 

Yes

Sessions are not discussed with education providers, GP’s or shared with a third party unless we think you or your child is at risk* (in accordance with the Inspire Wellbeing Services Child Safeguarding Policy or the Adult Safeguarding Policy).   

For further information on your data rights, please see our Privacy Policy on the Inspire Wellbeing Services website or you may request a copy in writing from hello@inspirewellbeingservices.co.uk 

Data Protection: For independent advice about data protection, privacy and data sharing issues, you can contact the Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF.  Tel: 01625 545745 or 08456 306060 Fax: 01625 524510 Website: www.ico.org.uk 

Is there any information you do not want shared?

Yes

Provide further details

Missed appointments policy 

Session appointments and cancellations

When you book an appointment, you are holding a space on our calendar that is no longer available to other people. Appointments are in high demand, and your advanced notice of any cancellations will allow another person to access that appointment time.

We understand situations arise when you may need to cancel or reschedule your appointment. If cancellation is necessary, we require that you telephone at least 24 hours in advance.

Appointments booked on a Monday will need to be cancelled on the previous working day (usually the Friday before) to ensure the cancellation is logged on our system and you are not liable for a cancellation fee. Our office is closed during the weekends and messages are not checked until Monday morning.

How to cancel your appointment

You can cancel your appointment by:

Calling 01245 914 701 or;

Emailing: hello@inspirewellbeingservices.co.uk

Late cancellations/no-shows

A cancellation is considered late when the appointment is cancelled less than 24 hours before the appointed time. A no-show is when a client misses an appointment without cancelling. In either case, we will charge the client the full amount of the appointment fee.

Emergencies and unforeseen circumstances

In case of emergencies or unforeseen circumstances, please contact us directly as soon as reasonably possible to discuss your situation. In the event that Inspire Wellbeing Services cancels a session due to an emergency or unforeseen circumstances you will not be charged for the session. We will endeavour to notify you of any changes as soon as possible and will offer you an alternative session time.

I have read, understood and agree to the missed appointment policy

Yes

Ending sessions

Referral to another specialist

There may be instances in which it becomes apparent that a referral to someone with a different specialism is required.  In this case we will offer you an alternative therapist where possible, or we will signpost you to another organisation. This is to ensure that you receive a service that matches your needs.  Your options will be explained to you.

Service termination

Both parent(s)/ carer(s) and/or the child/young person may end the counselling relationship at any time, without penalty or prejudice (with the exception of late cancellations/no shows)

While free to discontinue services at any time, it is preferable to have a closing session or phone call, to ensure the child/ young person understands that counselling is ending and to provide an appropriate closure to the experience.

I consent to have this website store my submitted information so Inspire Wellbeing Services can respond.

Signature

By your signature below, you are indicating that you have read and understood this consent form and that any questions you had were answered to your satisfaction.

I consent to receiving support from Inspire Wellbeing Services under the agreement terms above:

Signature

Sign Here

First Name

Last Name

Date

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