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Child Consent Form



The purpose of this form is to share some important principles, which guide my therapeutic practice so that your decision to place your child/adolescent into therapy with me can be based on accurate, informed expectations. Please read this carefully and feel free to ask any questions about what you have read if you need further clarification.


Therapy is a process, which relies heavily on building a trusting relationship between therapist and client. This takes time in order for a person to open up and for the therapist to understand what he or she is struggling with. In order to do justice to your child or adolescent they need time to be in a process that is going to bring them long term change and back on the developmental path that they may have lost a footing on.


In general one of the most important rights the person seeking therapy has involves confidentiality, even if it is a young child.  Information revealed by a client during the sessions will be kept strictly confidential and will not be revealed to any other person or agency without written permission, with the following exception:

Confidentiality has some legal limits as well. There are situations where the therapist can be required to reveal information obtained during therapy to another person without the parent or child’s permission. These situations involve harm to self, harm to others and any safeguarding concerns. Whenever possible the child/adolescent will be informed before these concerns are shared


Therapists who work with children have the difficult task of protecting the child/adolescents right to privacy while at the same time respecting the parent’s or guardian’s right to information.

Therapy is most effective when a trusting relationship exists between therapist and client. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children/adolescents and their parents. However, it is often necessary for the child/adolescent to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy.

It is useful if you do not ask your child/adolescent what they discussed after each session. However, if they wish to share anything with you that is their choice but they should not feel pressurised to do so.

If it is necessary to refer your child to another mental health professional with more specialised skills, I will share that information with you and recommend an appropriate referral.

I will not share with you what your child/adolescent has disclosed to me without your child’s/adolescent’s consent. (However, this is not applicable if it is a safeguarding concern). At the end of your child’s/adolescent’s treatment, it may be helpful to review the sessions in general.


It is helpful to remember that our relationship is professional and not social. Our professional relationship is of utmost importance as we work together towards achieving your goals and bringing resolution and healing to your child/adolescents life.

If you have any concerns regarding your child/adolescent during the therapeutic process, please email me at  I am available Monday to Friday from 9am to 5pm and will respond to you as soon as I can. 

Please understand that my therapeutic relationship is with your child/adolescent and therefore I cannot keep any concerns that you share with me from your child/adolescent.


Both you and your child or adolescent are in complete control and may end the therapeutic relationship at any time. Endings are an important part of the therapeutic process, in order to manage an ending appropriately with your child/adolescent I require at least two week’s notice prior to an ending.


After the initial assessment and consultation of 1.5hrs, subsequent sessions last 60 minutes.  If it is a physical visit to my treatment room, you are welcome to leave and return or wait outside.

I require 48 hours cancellation notice prior to the session, if appointments are not cancelled within this time frame, then fees will still be due.


Fees can be payable by transfer, up to 24 hours before the session is due. ( I will supply you with my bank details).  If you wish to pay by cash, please do so straight after the session.


Please understand that I am not a crisis service. In the event of an emergency please contact your GP or go to your local A&E or call 999.


The only data I collect is name, address, email and telephone number of the parent/carer of the child or young person that I am working with. I am obliged to keep notes of the key issues that is discussed during the sessions and they will be kept for six years, then they will be destroyed by a shredder.


I confirm that my child is fit and well and does not have any symptoms of COVID-19 as listed by the UK Government.

I agree to inform Marlene if my child show signs of COVID-19, and I will immediately refrain from him/her from attending therapy and will follow the government guidelines in relation to COVID 19.

I also understand that I need to confirm that my child is “symptom free” and can return to sessions.


By your signature below, you are indicating that you give your permission for your child/adolescent to be in therapy with Marlene EnerChi Vibes, and that you have read, understood and agreed to the information provided by this consent form.

Please return this form to me prior to your child’s appointment.

Child's Name(Required)
Parent/Guardian Name(Required)
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This field is for validation purposes and should be left unchanged.