Couples Intake & Consent

(This form can be completed individually or by both partners jointly — your choice. Please ignore all duplicate fields if you are filling this form out individually.)

Nature of Services: We understand that we will be receiving counselling services from Arian Abyaneh (Ari) at Ari’s Therapy. Counselling may involve discussing difficult or uncomfortable topics related to our personal experiences, relationships, emotions, thoughts, behaviors, etc. in order to work towards agreed upon goals.

Risks and Benefits: Potential benefits include improved relationships, solutions to specific issues, greater self-awareness and understanding. Potential risks include experiencing uncomfortable feelings like sadness, guilt, anger, or anxiety when discussing difficult aspects of our lives. However, counselling has been shown to have benefits that outweigh the risks for most people.

Confidentiality: All information disclosed within sessions is confidential and will not be revealed to anyone without written permission, except where disclosure is permitted or required by law (e.g. suspected child abuse, potential harm to self or others, court order, insurance purposes).

Rights: We understand that we have the right to ask questions about the counselling process, techniques used, credentials of the therapist, and other relevant information at any time. We have the right to end counselling at our discretion.

Consent: We voluntarily agree to receive counselling services and understand we can withdraw consent at any time. We will work collaboratively with our therapist to establish goals and treatment plans.

“No Secrets” Policy: When I provide couples therapy, I treat the relationship as the client. Because the focus is the relationship, I maintain a No-Secrets Policy for couples therapy, meaning that I will not agree to keep material secret from one partner when it is relevant to the couple’s therapy or could reasonably affect the relationship or treatment.

At times, individual sessions with each partner may be required for various reasons. Information disclosed in an individual session that is relevant to the relationship may be shared with the other partner during couples sessions or as otherwise clinically indicated. Before sharing clinically sensitive material, I will normally encourage the disclosing partner to share it in session, and I will attempt to manage the disclosure in a way that minimizes harm.

If a partner requires strict confidentiality for material they do not want the other partner to know, they are advised to seek individual therapy instead. This policy helps prevent conflicts of interest and preserves fidelity to the treatment unit.

Payment Information: We understand and agree to the following payment terms:

• Payment is due after each counselling session. 60 minute sessions are billed at $160 per session and 90 minute sessions are billed at $240 per session.
• An invoice will be emailed to us on the same day following the session.
• The accepted method of payment is e-transfer. Payments should be sent to ari@aristherapy.ca
• We agree to submit payment within 24 hours of receiving the invoice.
• If we need to make alternative payment arrangements, we will discuss this with the counsellor in advance.
• A 24-hour cancellation policy is in effect. Missed sessions may be billed at 100% of the session rate.

Online Counselling Sessions: We understand that counselling services are provided online through video conferencing platforms. By consenting to online sessions, we acknowledge and agree to the following:

• Technology Requirements: We require a computer and internet connection for online sessions. This includes a device with a camera and microphone, and a stable internet connection.
• Privacy and Confidentiality: While the counsellor will take all reasonable precautions to protect our privacy, we understand that online communications are never 100% secure. There is a potential risk of unauthorized access or technical difficulties that may compromise confidentiality.
• Session Environment: We agree to participate in online sessions from a private, quiet location where we will not be overheard or interrupted. We will not record the session without prior agreement from the counsellor.
• Technical Difficulties: If technical issues arise during a session, we will attempt to reconnect. If reconnection is not possible, we will reschedule or continue by phone if appropriate.
• Emergency Situations: We understand that online counselling may not be suitable for emergency situations. In case of an emergency, we agree to contact local emergency services or go to the nearest emergency room.
• Data Storage: Session notes and other relevant information will be stored securely in accordance with privacy laws and professional standards.

Couples Therapy Intake Form

(This form can be completed individually or by both partners jointly — your choice. Please ignore all duplicate fields if you are filling this form out individually.)