Service AGREEMENT PLEASE READ AND SIGN BY CLICKING AGREE ON THE ONLINE FORM FOLLOWING, PRIOR TO SEEING Dr. Abuziznadah and the Muslim Food Bank CONFIDENTIALITY: Confidentiality means that Dr. Abuziznadah and the Muslim Food Bank has a responsibility to safeguard information obtained during counselling. All identifying information about your assessment and treatment is kept confidential, except as mandated by law. You must sign a release of information before any information about you is given to anyone, except as mandated by law. In certain situations, mental health professionals are required by law to reveal information obtained during therapy to other persons or agencies without your consent. In such situations, Dr. Abuziznadah and the Muslim Food Bank is not required to inform you of her actions. Please note the following exceptions to confidentiality: • Confidentiality does not apply to cases of suspected abuse/neglect of children or the elderly. • Confidentiality does not apply to cases of potential harm to self or others. • A mental health professional may disclose confidential information in proceedings brought by a client against a professional. • Confidentiality does not apply to cases involving criminal proceedings, except communications by a person voluntarily involved in a substance abuse program. • Confidentiality may not apply in cases involving legal proceedings affecting the parent-child relationship. • Confidentiality may not apply to cases involving a minor child. In such cases, the mental health professional may advise a parent, managing conservator or guardian of a minor, with or without minor’s consent, of the treatment needed by or given to the minor. Dr Abuziznadah and the Muslim Food Bank dose not provide psychotherapy in Canada, she provides counselling only. You consent to receiving emails from Dr Abuziznadah and the Muslim Food Bank. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT: Dr. Abuziznadah and the Muslim Food Bank is required by law to protect the privacy of your health information. Although your counselling record is the physical property of Dr. Abuziznadah and the Muslim Food Bank the information contained in your health record belongs to you. You have the right to: • request a restriction on certain uses and disclosures of your information • inspect and obtain a copy of your health record • amend your health record as provided by regulation • obtain an accounting of disclosures of your health information as provided by law • request communications of your health care information by alternative means or locations • revoke your authorization to use or disclose health information except to the extent that action has already been taken. THE BENEFITS OF COUNSELING: One major benefit that may be gained from participating in counselling is the resolution of the concerns brought to therapy. Other possible benefits may be a better ability to cope with marital, family and other interpersonal relationships, and /or a greater understanding of personal goals and values. THE RISKS OF COUSNELING: There are certain risks involved in counselling. You may experience a variety of negative emotions during therapy as you remember and therapeutically resolve unpleasant events. Seeking to resolve concerns between family members, marital partners, and other persons can similarly lead to discomfort as well as relationship changes that may not be originally intended. The greatest risk of counselling is that it may not by itself resolve your concerns. Dr. Abuziznadah and the Muslim Food Bank will do her best to assess progress and provide referral to other sources if that is deemed necessary and appropriate. Counselling is a collaborative process and the progress you make will depend in large measure upon your investment in the process. Dr. Abuziznadah and the Muslim Food Bank will not be libel for under aged clients whom have parents’ consent . COST OF SERVICE The cost of service is stated on the booking page. PAYMENT OF FEES: this service is free. CANCELLATIONS: Cancellations must be made 48 hours in advance to avoid exclusion from the counselling service. *
