Please print off this page and send it to us if you would like your child to be included in the research
Parental Registration and Consent Form Patient Ref
Your Name
Relationship to child
Your Childs Name
Your Childs Age
Your Childs main symptoms
Address
Telephone Number
Mobile Number
I ..am the legal guardian/ parent (s)
of and hereby declare that:
● I/ we are willing for my/our child to take part in Research to assess homeopathic treatment for children with autistic spectrum disorders, behavioural and learning difficulties and/or developmental delay, Yes/No
● I/we understand that Homeopathic treatment in no way guarantees improvement in symptoms Yes/No
● I/we are willing to fill in questionnaires when requested to do so, so that the results of Homeopathic treatment may be externally validated and assessed. Yes/No
● I/we are willing to video/photograph my child if requested & possible Yes/ No
● I /we are willing for the results of this research to be published and also to be used in teaching. I understand that any published or teaching material will be written in such a way that my child will not be identifiable unless I agree to that separately at a later date. Yes/No
● I/we understand that I/we may withdraw consent at any time thereafter without the need to justify my/our decision. I may do this by notifying Charlotte Haynes of my wishes in writing. Yes/ No
Signed ........(Guardian/ parent) Date:
Signed Practitioner Date .
Information for parents: Homeopathic treatment will be prescribed as in normal Homeopathic practice. The research aspect of this study is the collation and use of the results not the actual treatment or remedies given.
Please send this form with a registration fee of £20 (made out to Charlotte Haynes) to
Charlotte Haynes 4 Lansdowne Road, Tonbridge, Kent TN9 1JB
Any queries please ring 07971409436 or email mail@homeopathy4kids.com
The fee will be returned to you if for some reason you are unable to go ahead with the research.