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Confidential Client Intake & Informed Consent

Please complete this form as accurately as possible. All information provided is strictly confidential and used to facilitate your clinical sexology services. This Confidential Client Intake & Informed Consent form is for new clients booking an initial or couples consultation. If you are returning for a follow‑up session, you do not need to complete this form again unless we specifically ask you to update your details.

Date of Birth
Month
Day
Year
Country
Relationship Status
Single
Dating
Married / Civil Union
Domestic Partnership
Separated / Divorced
Widowed
Polyamorous / Ethical Non-Monogamy
Type of Consultation
Individual
Couples / Multi-partner

Select all that apply to your current situation.

Please describe the primary reason you are seeking support at this time.

Safety & Wellbeing

Are you currently experiencing any coercion or pressure regarding your sexual choices?
No
Yes
Unsure / Prefer to discuss in person
Are you currently at risk of harm to yourself or others?
No
Yes

Please list any specific safety concerns or partner information relevant to your intake.

Informed Consent Acknowledgements

1. Nature and Scope of the Service

Consultations with Dr. Mohamed Arafa Clinical Sexology provide clinical sexology education and sexual counselling

intended to support sexual wellbeing, sexual confidence, intimacy and related concerns. Online counselling does not

replace an appropriate in-person medical or mental-health assessment when physical examination, diagnostic testing,

medical treatment, prescription medication, emergency intervention or specialized psychological/psychiatric care is

required. Referral to an appropriate locally licensed professional may be recommended.

2. Online Consultation

Consultations are conducted remotely using electronic communication technology. Virtual consultations offer

convenience and accessibility but may involve limitations, including technological failure, interruption, reduced ability to

assess some conditions remotely, and privacy or cybersecurity risks. I agree to participate from a reasonably private

location and, where possible, use a private device and secure internet connection. If the connection fails, I consent to

administrative contact using the telephone number or email address I have provided to arrange continuation or

rescheduling.

3. Confidentiality and Privacy

Information disclosed during consultations and information contained in my client record will be treated as confidential,

subject to applicable legal and professional requirements. There may be circumstances in which information must or

may be disclosed without my consent where required or permitted by applicable law, including serious safety concerns

or other mandatory legal obligations. Personal information will not ordinarily be disclosed outside the purposes for which

it was collected without appropriate consent or another lawful basis.

4. Recording

Consultations will not be routinely audio- or video-recorded. Neither the practitioner nor the client should record a

session without the prior express agreement of all participants. If recording is proposed for a specific purpose, separate

express consent will be obtained before recording begins.

5. Couples Consultations

For couples consultations, each participant takes part voluntarily. Both participants are expected to respect the privacy

of information discussed during sessions. Any policy concerning information disclosed individually by one partner will be

explained before couples work begins.

6. International Clients

I am responsible for accurately providing my country and physical location at the time of each consultation. Professional

rules and permitted services differ between jurisdictions. The practice may determine that services cannot be provided

or continued in a particular location and may recommend an appropriate local professional instead.

7. Emergencies

Dr. Mohamed Arafa Clinical Sexology is not an emergency or crisis service. The website, email, booking system and

counselling service should not be used for urgent medical or psychiatric emergencies. If I believe that I or another

person is in immediate danger, I should contact the appropriate emergency or crisis service in my current location.

8. Communication

Ordinary email and text messaging may not provide the same level of confidentiality as a dedicated secure clinical

platform. I agree not to use ordinary email for emergencies or for unnecessarily detailed sensitive sexual or health

information. Administrative communication may be used for appointments, payments and practice matters. Marketing or

newsletter consent, if offered, will be separate and optional.

9. Fees, Cancellation and Missed Appointments

Consultation fees will be displayed or communicated before booking. Unless otherwise stated at booking, appointments

cancelled or rescheduled at least 24 hours in advance incur no cancellation fee. Late cancellations and missed

appointments may be charged the full consultation fee except in exceptional circumstances.

10. Voluntary Participation

Participation in counselling is voluntary. I may ask questions about the service at any time and may choose to

discontinue counselling. No particular outcome can be guaranteed

11. Consent and Acknowledgement

By signing below, I confirm that:

- I am 18 years of age or older.

- I have provided accurate information to the best of my knowledge.

- I understand the nature and limitations of online clinical sexology and sexual counselling.

- I understand the privacy and technological considerations associated with online consultations.

- I understand the limits of confidentiality described in this document.

- I understand that this service is not an emergency or crisis service.

- I understand that medical assessment or referral to another professional may be recommended when appropriate.

- I understand the fees and cancellation policy.

- I consent voluntarily to participating in online clinical sexology / sexual counselling.

- I consent to the collection and use of information I provide for the purpose of delivering and administering this service.

- I consent to receiving administrative emails concerning appointments, payments and practice matters.

Choose only one answer
I consent that I have read, understood and agree to al the sections in the consent
I don't agree and don't consent to some or all sections of the consent

Couple Consultation

Building stronger foundations and deeper connections together.

2 hr
300 Canadian dollars
Location 1

Service Description

A dedicated space for couples to work through challenges, improve communication, and strengthen their connection. These sessions provide professional guidance and tools to navigate relationship dynamics in a supportive environment.


Cancellation Policy

The intake and consent form should be filled out before the initial and couple consultations


Contact Details


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