Consent Form — Minor template

1. Nature of Services

• As the parent or legal guardian, I have been informed of the nature, purpose, and expected format of the services to be provided to the named minor, and have had the opportunity to ask questions.

2. Parental Responsibility

• I confirm that I hold parental responsibility for the minor named below and have the legal authority to provide consent on their behalf under the laws of England and Wales.

3. Risks and Benefits

• I understand that, as with any service, there may be risks and benefits, and no specific outcome can be guaranteed. Age-appropriate adjustments will be made where relevant.

4. Confidentiality and Safeguarding

• Information will be kept confidential in accordance with UK GDPR and the Data Protection Act 2018, save where disclosure is necessary to safeguard the welfare of the minor or as required by law.

5. Right to Withdraw

• I understand that I may withdraw consent at any time on behalf of the minor, and that the minor's own wishes will be considered where age-appropriate.

Minor's Information

• Minor's Full NameText
• Date of BirthDate

Parent / Guardian Information

• Full NameText
• Relationship to MinorText
• AddressText
• Phone / EmailText

Practitioner Information

• Practitioner NameText
• Licence No.Text

Emergency Contact

• Contact NameText
• Relationship / PhoneText

Acknowledgment and Signature

• Parent / Guardian SignatureSignature
• Date signed (parent / guardian)Date
• Practitioner SignatureSignature
• Date signed (practitioner)Date

• By signing below, I confirm I hold parental responsibility and voluntarily consent to the named minor receiving services.