Child’s relationship with siblings in the following areas

ارتباط کودک با خواهر/برادر در زمینه های زیر

Pregnancy and Birth

بارداری و تولد

Growth and Development

رشد و تکامل

Medical History

سابقه‌های پزشکی

Child’s interest in the following activities

علاقه کودک به فعالیت‌های زیر چگونه است؟

I, the undersigned parent/legal guardian of the child, confirm that all the information provided in this form has been completed carefully and accurately to the best of my knowledge.

I also give my consent for the following:
1. Based on treatment protocols, interventions involving the child’s sensory and motor activities—which may include safe and controlled physical touch—may be conducted by the clinical team.
2. If necessary, therapeutic or educational programs outside the clinic (such as home exercises or social activities) may be recommended to support the child’s development.
3. All physical and psychological information regarding my child has been reported truthfully and accurately by me, and I take full responsibility for the information provided.
4. I consent to the possible use of my child’s photos or videos on the clinic’s social media or other educational/advertising platforms. The clinic commits to ensuring that the child’s face will be blurred or identifying features removed so that the child’s identity remains confidential.

🔒 Grow Counseling Clinic is committed to keeping all information and materials strictly confidential and to using them solely for assessment, treatment, and educational purposes.