Clients - Session Observation Consent Form

Session Observation Consent Form

To be completed by staff:

Client Email Address *

Client Nearest Clinic *

Treating Clinician, Technician, or Support Worker Name *

Trainee Staff Member Name *

Permission is to be granted for the following duration of time:

For the duration of treatmentUntil revokedUntil specified date

By whom? *

What date? *

Date / Appointment Further Details(If applicable)

To be completed by the client:

Direct Focus Solutions (DFS) has identified that your treating clinician, technician or support worker as listed above intends to work in future to help train a new member of staff within their future role in the organisation.

DFS would be most appreciative if you would fill in this form in order to grant permission for the identified staff member to be trained (trainee staff member) to attend one or more of your future appointments as listed above.

The trainee staff member will (unless noted differently above):

Perform a strictly observational role within your appointment.
Will not interact with you and will speak only to your treating clinician / technician / support worker.
Not entail any additional cost from you as part of your service delivery.

By signing this form, I give permission for the trainee staff member identified to:

Attend my appointments as specified
Take notes for their own professional development
Perform an observation role within the setting(s) my services are being delivered in

Client Name *

Name of Parent / Guardian / Representative(If applicable)

Client / Parent / Guardian / Representative Signature *