PSYCHOLOGICAL COUNSELING INFORMATION AND CONSENT FORM

“Psychological counseling is a professional support process provided by experts to help individuals understand themselves, gain self-awareness, identify and address their problems, make healthy decisions by discovering their emotions and thoughts, and establish effective communication and harmony with their surroundings.”

During the period in which you receive psychological counseling from us, you, as a client, have certain rights and responsibilities.

This form has been prepared to inform you about the counseling process, your rights, and your responsibilities. By signing this form, you acknowledge that an agreement has been reached between you and the counselor regarding the matters specified herein. Please read this form carefully.

This Psychological Counseling Information and Consent Form (“Form”) has been prepared to inform you, as the client, about the scope, boundaries, and ethical principles of the individual psychological counseling service you will receive through psychological counseling.

The counseling process aims to support your mental well-being, enhance psychological awareness, and develop coping skills for the challenges you face. Before starting your consultation with a Private Palz Home Care Center (Palz Sağlık Limited Company) via the ELRA Remote Health Service Platform (“Remote Health Information System”) and before receiving remote healthcare services, please read the following terms carefully and confirm your consent by approving this form.

1. All counseling sessions are conducted in accordance with the principle of confidentiality, and the client’s personal information is not shared with third parties. Sessions cannot be booked on behalf of someone else.

2. Client information is protected under the provisions of Law No. 6698 on the Protection of Personal Data (KVKK).

3. Confidentiality may be lifted in legally required situations (for example, when there is a risk of harm to self or others) and information may be shared with relevant authorities. Exceptions to confidentiality include the following cases:

• If the individual or their legal guardian gives explicit consent,
• If there is a clear and high risk of suicide,
• If the individual poses a risk of harm to self or others,
• If the individual expresses aggressive intentions toward others,
• If the individual has a fatal contagious disease and refuses to inform people who may be at risk,
• If the individual is a child who is being abused, a person who abuses a child or an elderly person (cases of abuse or neglect),
• If courts or competent authorities request information due to legal obligations.

In such cases, information will be shared only with relevant authorities and only to the extent necessary.

4. The session duration for instant sessions is 15 minutes and can be initiated immediately.

5. The session duration for scheduled appointments is 45 minutes and is conducted on the planned date and time.

6. The client is expected to attend sessions on time. Delays caused by the client cannot extend the session duration. To respect the time of both you and other clients, sessions begin and end as scheduled. If you cannot attend, you are expected to notify your counselor at least one (1) day in advance.

7. The principle of mutual confidentiality applies during sessions. Audio or video recordings are not made. The therapist may take brief notes with the client’s consent to support the process. If any issue arises that concerns the safety of the client or others, relevant authorities will be notified, and the session will be terminated after informing the client.

8. If the counseling service is requested for purposes other than its intended use, the process will be terminated immediately and the client relationship discontinued.

9. Informational or supportive content shared on the platform does not constitute a diagnosis or treatment. It is purely educational and advisory in nature. The institution is not responsible for any outcomes arising from its use.

10. The client is responsible for ensuring a stable internet connection to maintain the safety and continuity of the sessions.

11. In the event of a technical malfunction caused by the institution, the session will be rescheduled as soon as possible.

12. This service does not provide crisis intervention. In cases involving suicidal thoughts, self-harm, or the need for emergency psychiatric support, the client is advised to immediately contact the nearest healthcare facility or crisis support hotline.

13. There are no emergency services provided. Clients requiring immediate assistance should contact hospital emergency departments.

14. In cases of technical issues beyond the control of both the client and the counselor (e.g., loss of internet connection), whether to continue or terminate the session will be decided jointly by the client and the counselor.

15. The first session(s) are considered “preliminary sessions” aimed at understanding the client, learning about their concerns, and forming the basis for the counseling plan.

16. If deemed appropriate, the psychologist may consult with or refer the client to another psychologist within the same center.

17. If necessary, the psychologist may refer the client to a psychiatrist, neurologist, or institutions specializing in speech and language disorders.

18. During online sessions, the client must keep their camera and microphone on. If either is turned off, the session may be terminated.

19. Clients participate in sessions voluntarily. Even if referred by others, they may discontinue counseling at any time if they no longer wish to continue.

20. The psychologist may choose to administer psychological tests during the counseling process. The client will be briefly informed about the test, and it will only be administered with their explicit consent.

By signing this form, I acknowledge that:

• I understand the scope and limitations of the service provided.
• I have been informed about confidentiality principles and data security.
• I have been verbally informed by the social worker/psychologist named ……………………………………… regarding the matters described above.
• I agree to receive psychological counseling services from Private Palz Home Care Center via the ELRA Remote Health Service Platform in accordance with its working principles and procedures.
• I voluntarily consent to receive counseling services through Elra Psychologist.

Name – Surname:

Date:

Signature: