AERIALVIEW COUPLES COUNSELING AGREEMENT & CONSENT FORM

Welcome, and thank you for choosing Aerialview for your relationship journey.

This form outlines the therapy process, confidentiality, and boundaries.

Please read each section carefully and provide your consent to proceed.

Your responses are confidential and will only be used for therapeutic purposes.

Purpose of Therapy -
My goal is to provide a safe, non-judgmental, confidential, and growth-oriented space for you to explore your thoughts, emotions, behaviours, and life experiences.

Together, we will work toward emotional clarity, healthier coping patterns, meaningful relationships, and long-term wellbeing.

My Promise to You -

I will show up with:

Warmth, respect, empathy, and professionalism
Research-based tools and structured guidance
Non-judgmental listening and ethical practice
Commitment to your growth and safety

Fill the information of the female in the couple

Name *

Email Address

Phone *

Date of birth *

Educational background

Occupation

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Fill the information of the male in the couple

Name *

Email Address

Phone *

Date of birth *

Educational background

Occupation

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Relationship Background

Please provide basic details about the relationships, concerns for therapy and emergency contact.

How long have you been together? (Months & Years)

Are you legally married? *YesNoPlanning to Marry/Engaged

Have either of you been in couples counseling before? *YesNo

If you have been in couples therapy before, was it helpful?

How did you both meet each other? *

On a scale of 1 to 10, how would you rate the current distress in your relationship? (1 being minimal distress, 10 being crisis level) (Linear scale) *

-

(Check all that apply) *

Consent to Therapy

Therapy is a process, not a quick fix. You may experience:

Discomfort while discussing deep emotions (this is normal)
Gradual and layered progress
Homework or reflection exercises between sessions

Together, we commit to:

Honesty
Consistency
Willingness to work through challenges with patience and openness

Please read the following statements and provide your consent.

Confidentiality & Its Limits

Your privacy is extremely important to me. Everything you share in therapy is strictly confidential, with the following exceptions (as per ethical guidelines):

Confidentiality will only be broken if:

There is risk of harm to yourself or someone else
There are serious safety concerns (self-harm, abuse, or violence)
I am required to comply with legal or court-related obligations

No information will ever be shared with family, employer, partner, or anyone else without your informed consent.

Fees, Scheduling & Cancellation

Duration: 60-90 minutes
Mode: Online (Video/Audio) or Offline by appointment
Frequency: Weekly/Bi-weekly (decided mutually)
Format: Reflection, dialogue, coping tools, worksheets (if needed)
Tests, Assessments, Scales, etc. (as and when needed)

I follow a sliding scale structure, acknowledging unique case-to-case needs.
Sessions must be prepaid to confirm your appointment.
If you need to reschedule, please inform at least 24 hours in advance.

Less than 24-hour notice or no-shows will be considered a billed session.
This ensures mutual respect and smooth scheduling for all clients.

Communication Boundaries

To maintain a healthy therapeutic relationship, I request:

What therapy is -
✔ A professional, confidential healing space
✔ For emotional wellness, clarity, coping, and behaviour change
✔ Collaborative work between therapist and client

What therapy is not -
✘ Crisis hotline or emergency response
✘ Medical or psychiatric treatment (no diagnosis/prescription)
✘ Personal friendship, socialising, or dual relationship
✘ Advice on immoral, illegal, or harmful actions

Communication boundary:
Outside session hours, communication is limited to appointment scheduling or essential updates. Emotional processing should happen within sessions — where you have my complete attention and professional support.

Emergencies

If you are in immediate danger, self-harm crisis, or medical emergency, please contact:

Local emergency services
A trusted family member
A nearby hospital

Therapy cannot substitute emergency intervention.

Final Consent

By signing below, I voluntarily consent to therapy with Aerialview by Rizun Sharma (Counseling Psychologist, M.A. Psychology) and agree to the terms stated above.

Digital Signature of the male in the couple *

Digital Signature of the female in the couple *

Date *