SSRG Kids – Consent & Caregiver Information Form

"*" indicates required fields

Step 1 of 4 – Your details

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Please complete this form before your child’s first appointment. This information helps us understand your child’s care arrangements, identify who is authorised to make healthcare decisions and obtain consent for Occupational Therapy or Speech Pathology services.

We recognise that every family is different. Please complete the sections relevant to your child’s circumstances. If you are unsure about any questions, our team can assist.

1. Child's details

Child's full legal name*

Preferred name (if different)

Date of birth*

Pronouns (optional)

2. Parent, Guardian and caregiver details

Parent / Guardian / caregiver 1

Full name*

Relationship to child

Mother

Father

Parent (other description)

Legal Guardian

Foster carer

Kinship carer

Grandparent

Other

Phone number*

Email address*

Is this person a primary day-to-day caregiver?

Yes

Is this person authorised to make healthcare decisions for the child?

Yes

Unsure

Parent / Guardian / caregiver 2

Full name

Relationship to child

Mother

Father

Parent (other description)

Legal Guardian

Foster carer

Kinship carer

Grandparent

Other

Phone number

Email address

Is this person a primary day-to-day caregiver?

Yes

Is this person authorised to make healthcare decisions for the child?

Yes

Unsure

Who should we contact first regarding appointments and general enquiries?

Caregiver 1

Caregiver 2

Other

Are there any additional caregivers or important contacts we should record?

3. Care arrangements and legal considerations

Which best describes your child's current care arrangements?

Lives with one or both Parents

Lives across two or more households

Lives with extended family or another caregiver

Foster or kinship care

Residential or other statutory care arrangement

Other

Are there any parenting orders, child protection orders, guardianship arrangements or other legal decisions that may affect your child's healthcare or who can access their information?

Yes

Unsure

Are there any restrictions on who may contact, collect or attend appointments with your child?

Yes

Unsure

If you answered yes to either question, please provide relevant details or arrange to discuss these privately with our team

Is Child Safety involved in your child's care?

Yes

Unsure

If applicable, please provide the name and contact details of your child's Child Safety Officer or nominated caseworker

Can you provide relevant documentation confirming care arrangements or healthcare decision-making authority, if required?

Yes

I would prefer to discuss this with the clinic

Not applicable

4. Consent to therapy

Occupational Therapy and Speech Pathology support children to develop skills, participate in everyday activities and engage in activities that are meaningful to them. Therapy may include assessment, play-based activities, strategies and recommendations for home, education and community settings.

Your child’s therapist will discuss relevant assessments, interventions and goals with you.

Please confirm:

Please confirm*

I understand the general nature and purpose of Occupational Therapy and Speech Pathology.*

Please confirm*

I consent to my child receiving assessment and intervention as discussed with their therapist.*

Please confirm*

I understand that I can ask questions or withdraw consent for future services at any time, and that my child’s comfort and willingness to participate will be respected.*

5. Communication and information sharing

With your consent, SSRG may communicate with other people involved in your child’s care to support coordinated services.

Who may we contact?

Tick all that apply

GP or paediatrician

Other allied health professionals

School or early childhood education staff

NDIS support coordinator

Child Safety or nominated caseworker

Other

Other – please specify

I do not consent to additional information sharing at this s…

I do not consent to additional information sharing at this stage.

Names of people or services you authorise us to contact

What information may we share?

Tick all that apply

Relevant assessment findings and recommendations

Therapy goals and progress updates

Reports and written recommendations

Appointment coordination only

Consent

I authorise SSRG to share the selected information with the people and services nominated above. I understand that I can change or withdraw this permission at any time, subject to legal requirements. Information may also be disclosed where required or authorised by law.

6. Clinical photographs and videos

Your child’s therapist may recommend taking photographs or short videos for clinical purposes, such as documenting observations, movement, equipment or progress.

Do you consent to clinical photographs and videos of your child?

Yes, for clinical purposes explained to me, with my child’s agreement where appropriate.

Please discuss and request permission before each occasion.

No, I do not consent to clinical photographs or videos.

Declining consent will not affect your child’s access to therapy. This consent does not include promotional, website or social media use.

7. AI-assisted clinical documentation

SSRG may use AI-assisted scribing to help clinicians prepare clinical notes and documentation. Your clinician can explain how the tool is used and how your child’s information is handled.

Please indicate your preference

I consent to the use of AI-assisted scribing during my child’s appointments.

I do not consent to the use of AI-assisted scribing during my child’s appointments.

I understand that consent is voluntary and can be withdrawn at any time. My choice will not affect my child’s access to therapy.

8. Fees, payment and cancellation terms

Consent*

I have read or been provided with SSRG’s fee information and understand that fees vary depending on the service and funding arrangement.*

Consent*

I understand and accept SSRG’s payment terms and the requirement to provide at least 48 hours’ notice to cancel or reschedule appointments. Applicable charges may apply for late cancellations or non-attendance in accordance with SSRG’s terms.*

9. Parent / Guardian declaration

By signing below, I confirm that:

By signing below, I confirm that*

The information provided is accurate to the best of my knowledge.*

By signing below, I confirm that*

I have disclosed any relevant legal or care arrangements affecting consent or access to my child’s information.*

By signing below, I confirm that*

I am authorised to provide the consent indicated in this form, or have identified where further authorisation is required.*

By signing below, I confirm that*

I have had the opportunity to ask questions about my child’s care and the information provided in this form.*

Full name

Relationship to child / legal authority

Signature*

Your Name
Your Name
Your Name

Date

Additional authorised signature (if required)

Full name

Relationship to child / legal authority

Signature

Your Name
Your Name
Your Name

Date

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