Contact

Have you have attended EPT (remotely or in person) before?

Yes

I give consent for my information to be held by EPT Clinic for healthcare services in accordance with GDPR guidelines and for EPT Clinic to contact me in relation to healthcare services.

I give consent for myself and/or my child to participate in healthcare services as appropriate with EPT Clinic. I understand that this involves giving consent for personal and sensitive data to be held and used as described in EPT Clinic's GDPR policy.

If I enrol in online support in a group format, I agree to respect the confidentiality and privacy of others in my group.

I understand that EPT Clinic is a recognised training clinic and as such, trainee professionals and students are part of our team.

I give consent that EPT therapists liaise with other professionals (e.g. OT/GP) involved in the child's life as appropriate and in consultation with me.

YES

I give consent for the content for my feedback from evaluation questionnaires, and other feedback which I provide to be used for research, training and improvement purposes.

YES

In the case of separated parents, I confirm that both parents consent to this appointment.

YES

This is complicated - I will email you to explain on [email protected]

If I visit in person (e.g. for an assessment), I give consent for EPT Clinic to take a photo of my child for their file. This will help EPT to remember the child's face if you contact us in the future.

YES

Do you anticipate that you will require documentation for court proceedings or any legal involvement?

YES

If you are being funded by an organisation (e.g. Tusla, Respond Housing, HSE etc.) please name the organisation here:

HSE

TUSLA

Respond Housing

Other

Do you know what programme you are referring yourself for?

The Emotional Regulation Programme

Neurodiversity Essentials 5 Hour Workshop

Assessment

Neurodiversity Sensory Attachment Trauma (N-SAT) Programme

I confirm the answers I've given are true and correct to the best of my knowledge.

CONTACT

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