Child name:*

I consent to being contacted by Dyspraxia/DCD Ireland by email and/or phone, including after my child has availed of the service:*

I consent to personal data relating to my child being stored electronically on an online Cloud-based service. This service is encrypted and password-protected. Only staff with the appropriate level of security clearance will have access to the cloud-based service:*

I consent to all physical documents containing personal data relating to my child (such as physical assessment papers, letters and notes) being stored physically in a locked storage space, in a room with restricted access in the POTTS Telehealth lab in the University of Limerick. Only staff with the appropriate level of security clearance will have access to these documents:*

I consent for the use of information included in documents, communications and reports between the service and the family to be used as part of the assessment and any subsequent intervention processes:*

I consent to my child's local HSE healthcare/disability team being contacted and relevant information (including documentation and final report) being shared with the service:*

I consent to my child receiving occupational therapy intervention from registered occupational therapists and/or occupational therapy students who are supervised by registered occupational therapists (either face to face or telehealth/online via Zoom or Microsoft Teams):*

I consent to other agencies working with my child being contacted (such as GP, school, etc.) and relevant information being shared:*

I understand it is a requirement for health and safety that an adult is present at all times with my child during sessions. I understand that if this is not possible, sessions may be ceased until arrangements for this can be made:*

I consent to my child's emergency contact person (as outlined in my child's questionnaire) being contacted in the case of an identified emergency:*

I understand that my child will have to be supervised by an adult/caregiver while completing all exercises or recommendations during sessions or outside of sessions and that if there is any doubt in relation to the strategy, my child's ability to perform this safely or if my child experiences any discomfort or strain he/she/they should stop the activity immediately and report it to the therapist team:*

I understand that it is my responsibility to ensure that the location of any activities or interventions being undertaken by my child is deemed safe for my child:*

I consent to allowing mine and or my child's anonymised data, that does not identify me or my child, being used by Dyspraxia Ireland for audit, evaluation and scientific research purposes to ensure that Dyspraxia Ireland and the POTTS programme is best serving its participants (Your response to this will not impact your participation with the POTTS programme) (not required):

I consent to being contacted with information about further research studies on DCD via Dyspraxia Ireland (Your response to this will not impact your participation with the POTTS programme) (not required):

I understand that I can withdraw my consent for my child to engage in this service at any time. In order to do so I will email Potts@dyspraxia.ie and request, in writing, that my child be withdrawn from the programme:*

Parent/Guardian 1 name:*

Parent/Guardian 2 name:

I/we have read and understood the above statements. I/we understand I/we are free to ask questions about my/our child's service delivery at any time, and consent to my/our child engaging in the above-identified DCD/Dyspraxia Ireland and University of Limerick occupational therapy service:*

Parent/Guardian 1 signature/initials:*

Parent/Guardian 2 signature/initials: