Counselling Declaration Form

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First Name

Last Name

Email Address

Child’s Name (Full Name)

I, hereby declare that I am seeking free counselling for my son/daughter/ward for the sole purpose of improving his/her mental health and psychosocial wellbeing. I also confirm that I will not request information disclosed during the counselling sessions for the purpose of legal action in the form of child custody or other matters. I also fully understand that any attempt to involve ChildLine in such legal action will result in, but not limited to, an immediate termination of counselling service.

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