Informed Confidentiality and Consent Form
Welcome to Be Held Counselling.
I, Atiyeh Baradaran, am very happy to be able to serve you. Please carefully read the following professional therapy/counselling service terms and return the signed form to me via email. If you have any questions, don’t hesitate to reach out.
Confidentiality is a high priority at Be Held Counselling. All information you share with me is strictly confidential and will not be released without your voluntary and written consent. As part of routine practice, I may, on occasion, consult a clinical supervisor on your case in order to provide you with the best care. Your confidentiality will be strictly maintained and your name will not be used.
There are some limitations to confidentiality that may require a release of information without consent. These are, if there is a risk of child abuse, if there is a risk of suicide and if there is a risk of homicide.
If it appears that you are imminently about to harm yourself or someone else, I am ethically and legally obligated to let someone know. More important than the legal obligations, though, are my concerns for your health and safety, and that of those with whom you interact.
We will have our online sessions together on Zoom.
You will receive an invitation email from me the day before our scheduled session with the link to our meeting room.
You need a phone or laptop or computer with proper camera and sound system for our sessions. Please check the functionality of your device before our session, in order to save our scheduled time for helping you.
*You do not need to have the Zoom App downloaded. Just simply click on the link.
Fees and Cancelation
Each session is 1 hour, $120 per hour.
*Promotional offer until May 31/2021: Sliding scale of $80-$120 per hour
If you arrive part way through your allotted time, I will see you for the remainder of the time and you will be charged the regular session fee.
Payment is due at the time of the session and can be made through e-transfer or paypal.
If you wish to change or cancel an appointment, please provide 24 hours notice via email or phone. If you miss your appointment or do not provide 24 hours notice, you will be charged the full amount of the session.
IMPORTANT: Procedural Concerns for Phone and Video Counselling
Due to the nature of these modalities and possibility sessions may be interrupted using Zoom or with internet connections, it is important to note that you are agreeing to the potential of technical issues. If a technical issue occurs, we will contact you as soon as we can, to either resume the session or reschedule the remaining portion of the session. Although rare, there are times we may not have an internet connection or there may be a client emergency. If we are not online within ten minutes of our scheduled time, you will be given a credit for a session and we will contact you at our earliest opportunity to reschedule.
Please contact me by email at: Atiyeh.firstname.lastname@example.org. And I will return your email as soon as possible and within 2 days.
Please fill in the form below.