《Informed consent from parents/guardians/caregiver》

I give my consent for to be assessed for his/her Cognitive and Educational abilities. I am aware that assessment process will be carried out by Prakash Grover who is a Registered Psychologist and SLT. I am aware that Prakash will observe, assess and report with recommendations. I have had opportunities to ask questions and receive answers to them in this regard. The purpose of the assessment is mentioned in the referral form which is . I am aware that Prakash will use . and . and . as assessment tools. The cost of the assessment, report writing and discussion meeting including GST has been explained to me.

I understand that it is my responsibility to inform/request any special confidentiality matters, if there are any to Prakash before the assessment. There are no mentionable custody issues in this regard.

I understand that this assessment results will be shared with fellow Psychologists for peer supervision purposes. I have had opportunities to ask questions and receive answers to them.
I give my consent for the above.

Signature:

Name:

Contact details:

Relation with the client:

Date:

Name of the client

Email (We'll be sending you a copy of your Consent Form here)

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