Informed Consent

Guided Serenity Consulting

Wanda Chaulk, M.Ed.

Registered Provisional Psychologist
Goal and Purpose:
Guided Serenity Consulting is an intervention service that aims to help a child and/or the supporting team (home and school) to gain an understanding of a child’s challenging behaviour, to better understand the reasons why challenging behaviours are used, and to offer effective supports. This may be accomplished by promoting skill development in the student to make positive behaviour more likely, and/or through environmental changes that may more effectively support the child’s needs.
What can you expect of this service?
The staff of Guided Serenity Consulting will get an opportunity to observe and/or interact with your child in their typical childcare/school routines. For example, Wanda will observe the child in his/her setting (classroom, childcare) during lessons, group work, and unstructured time. Previous reports and assessments may also be reviewed. Afterward, a debrief may be held with the school and/or home team to share a common understanding of the child’s strengths and needs, and strategies may be offered to better support the child. The strategies can be modeled for the school team and family as needed.
Who is Guided Serenity Consulting
Wanda has more than 30 years of experience working with children, families, and schools in the capacity of a teacher, inclusive education supports, behaviour consultant, and more recently a Registered Provisional Psychologist. Following a cognitive behavioral approach, Wanda’s ultimate goal is to help children, families and childcare/school staff gain knowledge of the presenting challenges in order to better understand behaviours that can’t be changed (i.e., disabilities), and to empower the team with knowledge and courage to change behaviours that can be positively modified to meet the child’s needs
Confidentiality
To work collaboratively to support a child, information must be shared freely between all team members. However, information will not be shared externally without appropriate consent, unless required by law. All personal information, observation and assessment data will be stored in a secure manner either online or in a locked filing cabinet. Should staff of Guided Serenity Consulting become aware of any activity that could be harmful to the student and/or others, there is a legal obligation to report the behaviour to the appropriate persons and/or appropriate authorities. Guided Serenity Consulting staff will ensure all steps taken are documented and will be kept on file as legally required.
Fees
This service is being paid for by your school/childcare team. There are no associated costs for families.
Consent
Consent is valid for as long as Guided Serenity Consulting is providing you with service as directed by your childcare/school team. However, you are free to withdraw from this service at any time. If you do wish to withdraw from service, the risks and benefits will be described to you at that time. Please notify Guided Serenity Consulting, your child’s teacher, or the school administrator if you wish to withdraw.
• I permit Guided Serenity Consulting to review all pertinent documentation pertaining to my child’s program, or condition, to assist in maximizing his/her potential for success (e.g., medical, psychological, behavioral reports).
Signature
• I grant Guided Serenity Consulting permission to exchange information with all individuals directly involved in my child’s program (e.g., childcare staff, school staff, medical professionals, psychologist, other service providers) concerning matters relevant to the student’s support program. I understand that Guided Serenity Consulting will obtain written permission if the need arises to disclose confidential information about the student to anyone not directly involved with the program.
Signature
If there are any questions regarding the services offered by Guided Serenity Consulting or anything within this consent form, please contact Wanda Chaulk, Registered Provisional Psychologist, at 780-881-0034 or chaulkwanda@gmail.com prior to signing below.
Child Information
Child's Name*
Child’s Date of Birth*
Date Format: MM slash DD slash YYYY
Signature
Date
Date Format: MM slash DD slash YYYY
Parent/Legal Guardian Information (**if co-custody is in place, both parent signatures are required; separate forms may be signed, or both signatures on one consent form).
Parent Name*
Phone Number*
Relationship*
Signature
Date
Date Format: MM slash DD slash YYYY
Parent Name*
Phone Number*
Relationship*
Signature
Date
Date Format: MM slash DD slash YYYY
Guided Serenity Consulting

Wanda Chaulk

M.Ed Registered Provisional Psychologist

chaulkwanda @gmail.com

Phone: 780-881-0034

Hillcrest Montessori Academy

Informed Consent

Goal and Purpose:

What can you expect of this service?

Who is Guided Serenity Consulting

Confidentiality

Fees

Consent

• I permit Guided Serenity Consulting to review all pertinent documentation pertaining to my child’s program, or condition, to assist in maximizing his/her potential for success (e.g., medical, psychological, behavioral reports).

Child Information

@