PowerWood Client Information and Explicit Consent Form

Email *

Information about you *

Your Last Name *

Your Year of Birth e.g. 1985 *

Your Phone Number *

Your Postal Code

Country *

How did you hear about PowerWood and / or Simone de Hoogh *

Your educational / professional background *

Please provide your consent and/or acknowledgement of the following by ticking the boxes above each item:

When PowerWood collects information: Simone de Hoogh, PowerWood’s senior consultant and the PowerWood’s office staff will be creating and storing records if you contact the office, have a Free Introductory Talk, if you are a client, if you are following a course or training or are a participant of an event at which you have a talk with Simone de Hoogh. In this case we will need your explicit consent that we are allowed to create and store records concerning you and any third party we discuss.

Checkboxes *

Security: PowerWood Project CIC is committed to informing you about and ensuring that your privacy is protected while creating and storing records. We are committed to ensuring that your information is secure. In order to prevent unauthorised access or disclosure, we have put in place suitable physical, electronic and managerial procedures to safeguard and secure the information we collect online and in the office. All information personal information we receive from you will be processed in accordance with PowerWood’s Privacy Policy (details of below) and the EU’s General Data Protection Regulation (the GDPR).

Checkboxes *

Explicit Consent: By using our services you explicitly consent to us creating and storing records concerning your consultancies with the office and consultants, which may include educational, medical, psychological, economical, financial details concerning you, your child(ren), family, partner including external reports, medication, treatments and other issues affecting your general wellbeing.

About yourself

What would you like to share about yourself (if applicable)

Current Relationship status *

The current partner is (if having children)

Do you give PowerWood permission to share your information with your current partner?

First Name Partner (if applicable)

Last Name Current Partner (if applicable)

If you give PowerWood permission to share information with your current partner, please share your partners date of birth and birth place, to enable PowerWood verifying your current partner.

Place of Birth Current Partner

Your partners educational / professional background *

About your Children (if applicable)

What would you like to share about your children

1st Child's Name

D.O.B. 1st Child

Educational Situation 1st child

2nd Child's Name

D.O.B. 2nd Child

Educational Situation 2nd child

3rd Child's Name

D.O.B. 3rd Child

Educational Situation 3rd child

4th Child's Name

D.O.B. 4th Child

Educational Situation 4th child

Please provide your consent and/or acknowledgement of the following by ticking the boxes above each item: *

Simone de Hoogh is an ECHA Specialist in Gifted Education, Communication and Educational Consultant and a Life and Couple Coach. She is not a therapist and does not hold any medical qualifications. This means that she adopts a goal orientated approach and if during a session emotional blocks are encountered that prevent you from being able to communicate with her constructively it might be discussed that it is time to look for a therapist. Simone is also not a doctor and if you have any concerns about your health or the health of another you should always speak with your doctor.

Please provide your consent and/or acknowledgement of the following by ticking the boxes above of each item: (copy) (copy) *

Confidentiality. Everything you tell the consultant is confidential, however, she has a duty of care as a professional which may require her to breach this confidentiality in certain circumstances. E.g. if you would tell her that you were planning to kill the neighbour tonight she would have to take action. However, your consultant will try to not break confidentiality without discussing it with you first.

Please provide your consent and/or acknowledgement of the following by ticking the boxes above of each item: (copy) (copy) (copy) *

Although Simone de Hoogh is a professional, she believes that parents are the experts on themselves and their children. She believes that parents know what is and isn’t possible within their family situation, and what will and won’t work with their children and within their family. She believes that communication between yourself and your child/children, within the family, and also between yourself and the consultant is very important. For this reason, we hope you will feel free to share your thoughts with her in terms of how accurate her interpretations feel during your sessions. Likewise, please let her know whether the ideas and practical suggestions that are discussed work for you and your family. Your feedback is highly valuable as it gives our consultants the best opportunity to understand your situation and to support all of our clients. Please reflect on everything our consultants suggest, propose and advise in light of your personal beliefs and experiences and share your feedback with us. For example, you could say “I’ve tried that but that doesn’t work because…”, or “that would never work with my child because he or she would react…”. In our experience, all the tools and strategies developed within PowerWood can be adapted so they fit your personal situation. Your feedback will help our consultants learn and offer you the best individualised support available at PowerWood.

Please provide your consent and/or acknowledgement of the following by ticking the boxes above of each item: (copy) (copy) (copy) (copy) *

If a consultant ever says something that doesn’t feel right,that doesn’t sync with your lifestyle choices or doesn’t fit your belief system, please please make her aware. We believe it is most important to be true to ourselves as far as we are aware. Also, again, in our experience all tools and strategies can be adapted to your personal choices.

Please provide your consent and/or acknowledgement of the following by ticking the boxes above of each item: (copy) (copy) (copy) (copy) (copy) *

Can you please confirm you have read and agree to the Consultancy Services Privacy Policy on the PowerWood website: https://www.powerwood.org.uk/powerwood-consultancy-services-privacy-policy/

Please provide your consent and/or acknowledgement of the following by ticking the boxes above of each item: (copy) (copy) (copy) (copy) (copy) (copy) *

Can you please confirm you have read and agree to both the Terms and Conditions on the PowerWood website and the specific terms governing our Consultancy Services. https://www.powerwood.org.uk/powerwood-consultancy-services-privacy-policy/ and https://www.powerwood.org.uk/privacy-policy-cookies/

Please provide your consent and/or acknowledgement of the following by ticking the boxes above of each item: (copy) (copy) (copy) (copy) (copy) (copy) (copy) *

If you want to share any comments or feedback and don’t feel comfortable sharing it with your consultant, please feel free to write an email to directors@powerwood.org.uk. They will normally get back to you within seven working days.

If you are not the parent of the child you wish to talk to us about, please state your role and authority in relation to that child (e.g. legal guardian):

Your Name *

Date *

I confirm that the information given in this form is accurate and true to the best of my knowledge and belief: *

I confirm that the information given in this form is accurate and true to the best of my knowledge and belief.

Comment

Attribution

This legal document was created with the assistance of Rocket Lawyer.

What if you change your mind

Anytime you can withdraw this consent by sending an email to PowerWood’s Office with as subject “I’m withdrawing consent”, include your name and your paper data will be shredded and your digital data will be removed conform General Data Protection Regulation (GDPR).