Client Consent Form
Any person who wishes to work with Julie Aziz must agree to the following conditions. By typing your name at the bottom and returning this Client Consent Form by email to julieaziz@gmail.com, you indicate that you understand and agree to the terms and conditions stated below:
* You agree that you have read the separate section on confidentiality, below, and you agree with the terms set out in that section.
* You agree that you are at least 18 years or older.
* You agree to supply your true full name, email address, and phone number to Julie Aziz.
* You understand that while the intention is that motherself work be helpful to you, a positive outcome can not be guaranteed. If either party feels that working together is not helpful enough to you, either party is free to end the relationship at any time.
* If you are currently taking medication or receiving counseling for depression, anxiety, or any other psychological or psychiatric problem, you agree to disclose this information in the initial interview.
* You understand that motherself services are not a substitute for psychotherapy, mental health care, or substance abuse treatment. Julie Aziz will not make any formal diagnoses nor carry out traditional psychotherapy. Therefore, if at any point, she believes that your needs would be better served by a counselor, psychiatrist, or other mental health professional, she will inform you of this referral and may either require you to access these services as a condition of continuing work together, or she may decide it is necessary and more appropriate to end services completely.
* You understand and agree that certain situations including emergencies and crises are inappropriate for motherself services. If you are in crisis or in an emergency, you should immediately call 9-1-1 or seek help from a mental health professional or health care facility. Emergency situations include but are not limited to: if you have thought about hurting or killing either another person or yourself, if you have hallucinations or delusions, if you are in a life threatening situation of any kind, or if you are currently abusing or are addicted to alcohol or drugs. If you feel suicidal, you should call 9-1-1 or the National Suicide Hotline Toll-Free Number at 1-800-784-2433 or other local suicide hotline. You agree not to email Julie Aziz for help when you are experiencing these sorts of emergencies, both because she may not read your email right away, and because she is not the appropriate professional to seek help from at these times.
Confidentiality
What is said and written about in motherself work is something private to you, and thus Julie does not share this content with anyone else. This includes not sharing your name and contact information with other people. However, it is important to note that Julie can not guarantee the security of online or cell phone communications. Julie will only release information about you to others with your written permission, or if she is required to do so by a court order or legal subpoena. There are some situations in which Julie is legally obligated to breach your confidentiality and contact local law enforcement and/or social services authorities in order to protect you or other people from harm. These situations include the following: (1) If she learns that a child, elderly person, or disabled person is being abused or is at risk for being abused, she is required to notify the appropriate protective services; (2) If you indicate that you are considering committing suicide or committing any other serious self-injurious behavior, or are considering violence against another person, she is required to notify the appropriate authorities.
Nature and scope of services
Services provided by Julie Aziz will not include medical advice or psychotherapy. Julie Aziz will not be held responsible for the consequences of any plans, actions and/or results of actions you choose to take.
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