Theraplay | Ameliesplace

Name of the person completing this form

Child's intials

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What is a ‘Theraplay Informed’ intervention?

Theraplay® is a child and family intervention to build and enhance attachment, self-esteem, trust in others and joyful engagement. It is based on the natural patterns of playful, healthy interaction between parent and child and is personal, physical, and fun. Theraplay® interventions focus on four essential qualities found in parent-child relationships: Structure, Engagement, Nurture, and Challenge. The sessions create an active, emotional connection between the child and parent or caregiver, resulting in a changed view of the self as worthy and lovable and of relationships as positive and rewarding. During the intervention, the Theraplay® practitioner guides the parent and child through playful, fun games, developmentally challenging activities, and tender, nurturing activities. The very act of engaging each other in this way helps the parent regulate the child’s behavior and communicate love, joy, and safety to the child. It helps the child feel secure, cared for, connected and worthy. We call this “building relationships from the inside out.” (https://theraplay.org)

I have read and understood the above information

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Consent to records

This is an agreement between the individual completing this document and Amelie’s Place regarding this therapeutically informed intervention. To develop a deeper understanding of the children in your care, it would be helpful to review information stored on the local authorities servers about their journey into care/adoption. Similarly, it is important that we have either your PAR or Form F to gain a better understanding of your background, prior to commencement of this intervention to formalise risk assessments, to tailor the interventions to maximize  its effectiveness and to navigate sensitive subjects, whilst addressing the parent/carer or children in question.

Child's DOB

I provide Amelie's Place consent to access the above information for this theraputically informed intervention.

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Videotaping/Recording Consent

This is an agreement between the individual completing this document and Amelie’s Place regarding the videotaping/recording of this therapeutically informed intervention.  This therapy requires the use of videotaping/recording to deliver the service. It is necessary to use this method to enable supervision, feedback and analysis of the therapy provided by certified supervisors and/or clinical psychologists with a view that beneficiaries get the best possible service.  At the end of the intervention, all videos will be deleted unless you give us consent to use them for our ongoing training.  We will store contact details, electronic records and reports in accordance with General Data Protection Regulations (GDPR). The video footage will be stored on the therapist’s secure work drive, password protected and only available to the therapist. When we are required to pass video footage onto our therapeutic supervisors, this will be done via a secure method using encryption.

I provide consent on behalf of the individuals completing this intervention, to be recorded.

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Information Gathering Form

Disclaimer

This and subsequent documents are specifically focused on the most challenging aspects of your child/children’s behaviour, and your experience of those behaviours. We understand that this is not necessarily a reflection of the wonderful child you have or how rewarding, fulfilling and blessed you feel to be a parent. With this in mind, please attempt to answer these questions as honestly and truthfully as possible.

1. What are the three greatest challenges for you as a carer/parent, with regards to looking after your child?

5. What is you child like, when presented to a person they are unfamiliar with? Required

7. How does the child respond to structured activities? For example, games which have boundaries, rules, and/or directed by adults? Required

Highly tolerant

Tolerant

Challenging

Oppositional

8. How does the child respond to nurturing activities? For example, are they accepting of cuddles, touch etc? Required

Highly tolerant

Tolerant

Challenging

Oppositional

9. How does the child respond to challenging activities? For example, competitive games, games which have a clear “winner and loser” or games which push their competency level. Required

Becomes disinterested if not immediatly succeeding?

Become angry when challenged?

Tries to control what game or activity is being played?

Generally tolerant

2. What are your child's three emotional triggers (for example, being asked to go to bed, to come away from their tablet etc)

3. Effective methods to settle your child in heightened moments

4. What consequences are introduced, when your child in not conforming with boundaries within the family home?

10. How does the child respond to moments of emotional intimacy? For example, maintaining eye contact or standing in close proximity? Required

Avoidant

Uncomfortable

Comfortable

Seeks out emotional intiamacy

6. What is you child like, when presented to a person they are familiar with? Required

-Structure of intervention: In some instances, we can introduce the child into the dyad and, in others, we may be unable to. This is for lots of different reasons which are all orientated around the best interests of the child and/or the adults in question. It is at the practitioner’s discretion to determine how to use the allocated sessions and whether it is/is not beneficial to involve the child in this intervention.

Professional’s meetings: Although Amelie’s Place is committed to working in joint-up way with professionals, all practitioners are bound by confidentiality. Therefore, our contributions in professionals meetings will be made with this in mind, unless there is a safeguarding concern.

Safeguarding concerns: As social care professionals we have a statutory obligation to diseminate information to the relevant professionals if we believe there are actual or percieved safeguarding concerns. In our capacity as practitioners, it is not within our duristiction to determine or assess whether the information presented meets threshold for social care intervention. Due to this, we are required to delegate that responsibility to those who can make these determinations. Therefore, should we need to pass information to social care, it does not mean there is a safeguarding concern; it just means we are consulting those who can make these decisions, to ensure everyone in question is as safe and supported as possible.

Historic information: This document, along with historic information ( for example, carers form F, CPR, PAR and any reports from previous interventions) must be completed and returned/sent prior to the intervention beginning. We cannot start an intervention until we have this information.

Cancelled sessions: Parents/carers are asked to provide at least 48hrs notice if they need to cancel a session. We may be able to provide alternative dates for this missed session prior to our next meeting however, sometimes, this will not be possible. In the event that it is not possible to reschedule, this cancelled appointment will be included within your overall session count.

Holiday: Parents/carers are asked to provide at least four weeks’ notice if they are to miss sessions, owing to pre-planned holidays or known absences. With this notice period, we can explore rescheduling the missed appointments before the known absence or holiday. Similar to the above, in some instances, this will be possible. At other times, this will not be. In the event that it is not possible to reschedule, this cancelled appointment will be included within your overall session count.

Early termination: Should the parents/carers wish to terminate the therapeutic intervention, we would need a four-week written notice period of the intention to do so, detailing why they wish to discontinue the work. This will enable us to prepare an appropriate ending to the sessions for the parents/carers and the children in their care. Should the practitioner need to stop the therapeutic intervention due to unforeseen events, the LA and the parents/carers will be informed; a way forwards being discussed before the termination of a service.

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Important information

Reports: A report will be provided to the respective local authority at the conclusion of the intervention. Prior to doing so, Amelie’s Place will send a copy to parents/carers, offering the opportunity to share their thoughts and feelings on the information detailed in the report.  This feedback is extremely valuable to us, as we strive to continue to provide therapeutic services at the highest standard for each and every family we meet. We kindly ask that responses are returned within five working days, after which the report will automatically be sent to the local authority for processing.

GDPR statement: We will store contact details, electronic records and reports in accordance with General Data Protection Regulations (GDPR) on the therapist’s secure work drive, password protected and only available to Amelie’s Place.

I have read, understood and agree to the above

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Yes, we are happy to be contacted!

We would prefer not to be contacted

Is there any additional information which the facilitators will need to be aware of before this intervention begins? For example, are there any sensory issues (parent and/or child), food allergies (parent and/or child), specific learning or physical difficulties (parent and/or child) etc?

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By signing below you agree to the terms and conditions, as set out in the above document

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What is a ‘Theraplay Informed’ intervention?

Consent to records

Videotaping/Recording Consent​

Information Gathering Form

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Disclaimer

Important information

Thank you!

Videotaping/Recording Consent