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All About You Wellness Centre

Client Information Sheet for Relationship Counseling

Name : *

First

Last

Date of Birth *

Occupation *

Current Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

HK ID Card/ Passport Number *

Contact Number: *

Email: *

Gender *

Male
Female
Non – Binary
Prefer not to say

Status *

If divorced, how long:

Type of relationship you are seeking counseling for:

Have you ever done any coaching, counseling or therapy?

Yes
No

If yes, when?

What was the reason? *

Did it work for you? (Please explain.) *

Please complete the following sentences in your own words:

My relationships are: *

Money is: *

Life is: *

I am: *

What are the 3 major events that have shaped your life? Briefly describe how the event impacted you and state your age. *

Example: Age: 10, Event: My Grandfather died. So I felt lonely and abandoned. I experienced the sense of loss for the first time.

Please describe in your own words what you feel is the biggest issue in your relationship and what you would like to accomplish with in your couples counseling sessions. How you would expect your life to change once you accomplish it? *

What is your level of commitment to resolve your issue from the scale of 1- 10, Please Tick the scale below, 1= least and 10= most *

Are you in therapy or taking medication?

If yes, please explain.

What else would you like your practitioner to know about you?

Terms and Conditions

Cancellations must be made at least 24 hours prior to the scheduled appointment. If cancellations are made less than 24 hours the full session fee will be charged. Should the client fail to show up, the full session fee will be charged.
All prior payments are non-refundable and non-transferable, except in special circumstances and All About You (‘AAY’) reserves the right to the final decision.
The Client agrees that all practices done on, for, or even by them at AAY are done with their full consent and at their will.
The Client attests that they have no mental or psychological ailment/disorder and are not on any psychiatric or psychological treatments and/or drugs.
The Client agrees to indemnify, release, remise and forever discharge, the treating practitioner, AAY, its employees, its consultants, its property owners or anyone one at AAY from any obligation or liability whatsoever, all claims, demands, damages, injuries, actions or causes of actions whatsoever, before, during or after volunteering to participate in such sessions.
The Client is aware of the modalities of therapy used and understands that the result may also depend on external factors and the clients’ own efforts.

Privacy
By signing this form, you understand and agree: Your personal data (name, contact details, interests,) may be used by AAY to contact you and inform you about our latest news, events, promotions, offers, workshops, seminars and other exciting happenings at AAY. Please note that you may change your mind at any time and ‘opt-out’ of our mailing list by either writing to us at info@soniasamtani.com or by clicking ‘Unsubscribe’ in any of our email communications.

Confidentiality
All information discussed in the sessions will be treated as confidential information and will not be disclosed to any third party unless prior permission is granted or unless disclosure is required by law. However, counselors are ethically and/or legally required to disclose confidential information to the appropriate authorities in four kinds of circumstances:

● If a client indicates that they or another person may be a danger to themselves or others
● In the case of apparent, suspected or potential child abuse or neglect
● If clients report sexual abuse by a regulated health professional
● When a court issues a summons for records of testimony

From time to time your practitioner may consult another for supervision, in order to improve the quality of services provided, without using personally identifiable information. Other than the four circumstances listed above, your practitioner cannot converse, write or give any information about you or your circumstance, without your verbal or written informed consent to do so.

General – Informed Consent
The purpose of your sessions here is to help you improve your current circumstance(s) and our aim is to contribute to your well-being and growth. Sessions involve delving deep into the root of the problem/s and it is not uncommon for clients to feel an increase in symptoms before they feel better. However, the potential benefits of counseling are numerous. Should you have any questions, concerns or suggestions regarding the information provided above or any other aspect of the counseling process, feel free to discuss with your practitioner. Should you choose to discontinue sessions at any time it is highly advisable to discuss the reasons for considering this with your practitioner prior to acting on your decision.

I have read and accepted the above terms and conditions above.

(This agreement is valid from the date signed until further notice.)

Please type your name to confirm all the information above. This will serve as your e-Signature. *

Date Signed: *