AERIALVIEW THERAPY AGREEMENT & CONSENT FORM Welcome, and thank you for choosing Aerialview for your wellness 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 NamePhone *Email Address *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal codeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint HelenaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. MartinSt. Pierre & MiquelonSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Virgin IslandsUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweMarital StatusEnter your current marital situationNot married yetMarriedDivorcedWidowedEngaged / in a relationshipGender *MaleFemaleOtherDate of birth *Educational backgroundReason to take therapy / Problem at the momentEmergency Contact Person's NameRelationship with Emergency Contact PersonEmergency Contact's Phone NumberConsent to TherapyTherapy 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. You understand that therapy is a collaborative process focused on emotional wellbeing and personal growth. You understand that therapy may involve emotional discomfort and that progress takes time and consistency. You understand that your therapist will not provide medication or crisis intervention services. DO NOT CHECK THIS FIELD IF YOU DO NOT AGREE TO ANY OF THE AFORE-MENTIONED TERMS. NOTE THAT YOUR AGREEMENT TO THESE TERMS BY CHECKING THIS FIELD IS A RECORDED PROOF IF YOU CHOOSE TO CONTEST AGAINST THEM IN THE FUTURE. EXERCISE CAUTION. Confidentiality & Its LimitsYour 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.You have read and understood the confidentiality policy and its exceptions. Fees, Scheduling & Cancellation Duration: 50–60 minutes Mode: In-Clinic or Online (Video/Audio) by appointment Frequency: Weekly/Bi-weekly (decided mutually) Format: Reflection, dialogue, coping tools, worksheets (if needed) Tests (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. You understand the fee policy, scheduling terms, and 24-hour cancellation rule. 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. You understand and agree to the communication boundaries. 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. You understand that the therapist cannot provide 24/7 crisis support and you will reach out to emergency services in urgent situations. Final Consent *By signing below, I voluntarily consent to therapy with Rizun Sharma (Counseling Psychologist, M.A. Psychology) and agree to the terms stated above.Date *Submit