Consent Form - 2021
Consent is an ongoing process and is an on-going conversation. You will see us asking for permission before we do many activities and before we share any personal information with other people.

We invite you to speak up at anytime.

Before we start, we want to make sure that everyone's expectations are clear.

We also have alternatives to this google form if you prefer - just email us at info@inclusive-communication.co.nz

All of our policies are outlined in detailed on our website: www.inclusive-communication.co.nz/policies

Client name: *
Your name and relationship to the client (e.g., Jane, mother): *
Your email address or phone number:
Description of our service:
Our consultation, intervention, and assessment procedures are strongly grounded in research and evidence.

We explain as we go and we keep you informed. The exact details will evolve with the needs of the client, but as part of our consent process we need to let you know that

Assessment may include:
- play and conversation
- informal assessment
- gathering information from you via checklists and interview
- formal testing procedures
- speech and language sampling when we record what and how someone speaks
- written language sampling when we observe writing on paper or via technology

Intervention may include:
- play activities including gross motor, silly games, signing, and sensory activities
- conversation-based activities
- technology and apps to support our goals
- video modelling
I consent to Inclusive Communication providing speech-language therapy services which may includes informal assessment, formal assessment, intervention, organising assistive technology trials, and consultation with those you give us permission to contact (If you consent, please type YES) *
Photos, videos, and audio recording
Video and audio recording is an important tool for assessment, progress tracking, communicating with families/schools, and during therapy. It is impossible to fully analyze language and communication skills in the moment. Video and audio recordings are essential for us to complete some assessment tasks.

We only capture positive moments and always ask client permission before hand.

We store all electronic media on secure devices and cloud-based services. We use encrypted tools whenever possible and all data is always requires a password to access. Additional details can be found on our website. Clients and approved caregivers/parents can request a copy or link to the videos at any time.

From time to time, we provide training to schools and other agencies. Videos can be a powerful way to illustrate key concepts and advance our collective knowledge on how to be a more inclusive society. We may contact you to see if you would give permission for a specific video to be used in that contact. This is optional.

Do you consent to videos, photos, and audio recordings being recorded and used as described above? *
Information sharing and storage
We abide by the Privacy Act of 2020 and the Health Information Privacy Code of 2020. We strive to uphold the dignity and privacy of our clients and their families at all times.

We only collect information from families and clients directly or from other agencies who have consent from you.

We store all data securely on password-protected devices and encrypted cloud-based electronic storage. Full details are in our policies and you can request your information and/or corrections at anytime. By law we are required to store health information for at least 10 years, but we only collect what we need in order to provide our clinical services.

We also believe it is important for strong communication and collaboration with everyone on the team surrounding the child or client. With this in mind, we will need to work together to know your boundaries of who you approve to know which information. We always check before we share sensitive information.

We also confidentially discuss cases in supervision as part of our professional standards. We do this in a non-identifying manner, however this is one reason why we ask if there is anyone who is on your non-contact list.
Do you understand and agree with our information sharing and storage policy?
Clear selection
Who is the best person to ask permission from before we share information with others?
Is there anyone we should not share information with? We will always check first, but it is good to know if some people or agencies are on your non-contact list.
Any additional questions or concerns?
Submit
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