Pre-Check
Please confirm:
My child is between 5 and 11 years old.
My child is not in an acute mental health crisis.
No severe mental health condition without professional supervision.
My child wants to participate.
Attendance During Session
I will be present
I will stay in the room or within earshot.
I will not be present
I allow the session without my presence.
Hello!
What are we doing?
Together we'll find out where in your body a yucky feeling is hiding. Then we'll help your body let it go. In the end you'll feel better!
May I touch you?
Sometimes it helps when I gently place my hand on the spot where the yucky feeling is. You decide!
You can say STOP at any time.
Then we stop right away!
Then we stop right away!
My Name
(You can write or draw your name here)
Parent Confirmation
I have discussed this with my child.
I understand that FIVE MOVES® is not therapy.
My child made the touch decision themselves.
I allow my child to participate.
Parent/Guardian
With my signature I confirm all checked points.
Place, Date
Signature
Guide
Name
Signature
Guide Only