Consent Form

Client & Guardian Information
Client Full Name:

Date of Birth:

Age:

Gender:
MaleFemaleOtherPrefer not to say

Mobile Number (WhatsApp):

Email Address:

City / Area:

If the client is a minor (under 18 years):

Parent / Guardian Full Name:

Relationship to Client:
MotherFatherLegal GuardianOther

Primary Reason for Seeking Services:
Child & Adolescent ConcernsParenting Guidance & CounsellingBehavioral ConcernsAutism / ADHD / Developmental ConcernsLearning DifficultiesPsychometric & Diagnostic AssessmentCareer GuidanceEmotional Well-beingRelationship or Family IssuesOther

Brief Description of Concern

I Agree to Informed Consent & Service Agreement