Parent / Child Consent Form

Registration & Consent Form

Important information about you and your child's personal data

The Lejeune Clinic will collect certain information from you, as parent or guardian, and of your child, both on this form and throughout the provision of any speech & language therapy and occupation therapy that you take part in with us and any follow up to this. This information may comprise of personal details and health-care records. 

Personal details include: names, addresses, telephone numbers, date of birth, email addresses and email communications. Health-care records may include: developmental, medical and educational history, assessment findings and observations, SLT & OT intervention goals, progress and outcomes, session notes, written summaries and feedback documents.

Only information that is relevant or required to provide speech and language therapy services and occupational therapy will be collected and we will not pass it to anyone other than you and your child except with your permission or as required by law or to fulfil a regulatory obligation.  More detail regarding how we handle your information is available at our website privacy policy at

In order to process you/your child’s Health Information, we are required by law to obtain your consent. Please sign below on behalf of yourself and your child to confirm that you are happy for us to process this Health Information as described. If at any time you would like to revoke your consent, please contact us at: