Consent form

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Please delete as appropriate

I have read and understood, and agree to the contents set out within the Terms and Conditions document on www.janeclarkslt.co.uk.  

                                                                                                                             YES/NO

I consent to Jane Clark, Speech and Language Therapist, sharing relevant verbal and written information about my child with appropriate professionals. This includes the use of emails. These professionals may include Education staff, Educational Psychologists, Occupational Therapists, Physiotherapists, GPs, etc.

                                                                                                                            YES/NO 

I consent to my email address and telephone number being used to contact me and share relevant documents.  

                                                                                                                            YES/NO

I consent to my child being videoed/photographed as necessary in my child’s speech and language therapy sessions.

                                                                                                                            YES/NO

I have read and understood the COVID-19 Policy on www.janeclarkslt.co.uk. 

                                                                                                                            YES/NO

I have read and understood the Privacy Policy and consent to Jane Clark, Speech and Language Therapist, processing my and my child’s information in this manner and for the purposes stated in the policy.  

                                                                                                                            YES/NO

Child’s Name   …………………………………………………………………………… 

Date of Birth    ……………………………………………

Parent/Carer Signature  …………………………………………………………… 

Date   ……………….………………………………………

Print Name   ……………………………………………………………………………..