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All About You Wellness Centre

Client Information Sheet for Family Constellation

Date *

Name *

First

Last

Occupation *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

HK ID Card/Passport Number *

Contact Number (1) *

Contact Number (2) *

Email *

Gender *

Male
Female
Non-Binary
Prefer not to say

Please describe in your own words what you would like to accomplish in your session, and how you would expect your life to change once you accomplish it? *

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.
The client is aware that the session is private and only involves the client and therapist, and thus the client shall not bring children, friends or relatives to the session room unless they are related to the case and previously discussed with the therapist. The client understands that pets are not allowed at All About You centre and shall not bring any pets/ animals to the centre under any circumstances.

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

Your practitioner may be training other therapists or continuing their education. From time to time your practitioner may consult a senior for supervision in order to further their skills and improve the quality of services provided, or educate students on how to deal with certain circumstances. In such cases your practitioner will do so 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. You can choose to keep your relationship with your practitioner private and remain anonymous, and you are not obligated to interact with your practitioner publically or socially. Your practitioner will not initiate a conversation with you in public or engage unless you wish to do so.

General – Informed Consent
The purpose of your sessions 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 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: