Kaleidoscope Collective Consent Form * Please note that since this form is through Squarespace I cannot guarantee complete confidentiality. If you would rather email answers to my HIPPA compliant email instead, please do so at: contact@littlehouseartstherapy.com I understand Child's Name * First Name Last Name Child's Preferred Pronouns * Parent/Caregiver Name * First Name Last Name Parent/Caregiver's Preferred Pronouns * Parent/Carergiver Email * Parent/Caregiver Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone Number * (###) ### #### Safety * In the rare case of a medical emergency, I will call 911. In addition to this, who is your preferred healthcare provider to contact? Please note if you have a preferred hospital as well. Does your child have any accommodations or medical conditions? * Tell me a little bit about your child: * What are your hopes for this group and your child? * Consent to Photograph Artwork * Please check below your preference for Natalia Torres del Valle to photograph your child’s artwork for the following reasons: • Website (client’s name omitted) • Social media (client’s name omitted) I consent I do not consent Anything else you would like me to know? Thank you!
