Booking & Consent Form

This form is to consent to your child having Art Therapy sessions whilst in school.

Please only complete this booking form if you have been sent this link directly from Adélie Psychology or from your child’s school.

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Your booking form has been submitted

Child’s Name

Date of Birth (DD/MM/YYYY)

Full Address including Postcode

Parent/carer with Parental Responsibility (required for under 18s)

Phone

GP Surgery

School

Consent:

By submitting your information, you’re giving us permission to hold your data for the purposes of working with your child as per our privacy policy.

I consent to my child named above having Art Therapy sessions in school with Molly O’Connell

Yes No

Please use this space to let us know any other information which may be useful when working therapeutically with your child