Client Forms

CHILD'S DETAILS

First name *

Surname *

Date of birth *

Age

Home language

SIBLINGS

Add each sibling's name and date of birth

Name

Date of birth

PARENTS / GUARDIANS

MOTHER / GUARDIAN 1

Full name *

Relationship to child

Mobile number *

Email address

Home number

Work number

FATHER / GUARDIAN 2

Full name

Relationship to child

Mobile number

Email address

Home number

Work number

RESIDENTIAL ADDRESS

Street address / apartment *

Area / community

Emirate

PERSON RESPONSIBLE FOR ACCOUNT

Complete only if different from parent / guardian above

Full name

Relationship to client

ID / passport number

Occupation

Mobile number

Email address

IMPORTANT NOTICE

By submitting this form you confirm you have read the accompanying Client Information Document, understood your responsibilities, and that cancellations require a minimum of 24 hours' notice. Late cancellations will incur a 100 AED fee per session.

DECLARATION

Signature (type full name as signature) *

Date *

Signed at (location)

Your information is held in strict confidence.
Questions? info@lifestylebysharna.com

PLEASE READ CAREFULLY

This document outlines what you can expect from the therapy process and from Sharna as your attending psychologist. It also sets out your responsibilities throughout. Please read it in full — if anything is unclear, you are welcome to discuss it before your first session.

THE EVALUATION PHASE

Before therapy begins, an initial evaluation will take place. This involves a structured conversation to understand the nature of your concerns, your child's background, developmental history, relationships, and what you are hoping to achieve through the process.

THE THERAPEUTIC PROCESS

Therapy generally leads to improved functioning and personal growth over time. In the short term, it may feel unsettling, as it is often an emotional process.
For younger children in play therapy, temporary behavioural changes may occur as emotions surface — this is a normal part of the process.
The goal of therapy is to bring about meaningful change and to equip the client and their family with skills to sustain that change.
Sessions are 50–60 minutes unless agreed otherwise. Progress depends in part on the client's active participation in the process.
This practice does not provide expert witness testimony or legal evidence in any form, including custody or divorce proceedings. Assessment reports are intended solely to guide parents, teachers, and caregivers.

CONFIDENTIALITY

All information shared is treated as strictly confidential. Information will not be disclosed without your consent, with three limited exceptions:

Risk of harm: If there is a credible risk of harm to you, your child, or another person, the necessary steps will be taken to prevent it — which may require disclosing information.
Legal obligation: An Act of Parliament may require disclosure.
Court order: A court may compel disclosure. Every effort will be made to protect your privacy in this situation.

For clients under 18, parents or guardians will be kept informed about the overall progress of therapy. General session content will not be shared without the client's agreement, except where the child's safety or behaviour warrants it.

No report or medical certificate will be issued without your consent and without first giving you the opportunity to review and discuss it.

FEES & PAYMENT

Payment is due before or on the day of each session, via bank transfer or cash. Sessions will not proceed if fees are outstanding.
Cancellations require a minimum of 24 hours' notice. Late cancellations and no-shows will be charged a 100 AED cancellation fee per session.
If you arrive late, your session will be shorter but the full fee remains payable.
If you have difficulty paying, please raise this directly — where possible, arrangements will be made.
Outstanding accounts may be referred to a debt collection attorney. Legal costs in that event will be for the account holder's liability.

TERMINATION

Either party may end therapy at any time. Sharna will only terminate the therapeutic relationship in consultation with you and in a professionally responsible manner.

ACKNOWLEDGEMENT

I confirm I have read and understood this document *

I have read the Client Information Document in full and understand my responsibilities throughout the therapy process. I understand the confidentiality policy and its limited exceptions. I agree to the fee and cancellation policy, including the 100 AED late cancellation fee.

Full name *

Date *

INFORMED CONSENT FOR THERAPY

This form confirms your informed consent for Sharna Licht (Educational & Clinical Psychologist) to provide psychological services. Please complete all fields and sign below.

ABOUT THE CLIENT

Client's full name *

Date of birth

Type of service consented to *

CONSENT DECLARATION

I confirm all of the above and give my informed consent. *

PARENT / GUARDIAN SIGNATURE

Full name *

Relationship to client *

Signature (type full name) *

Date *

CLIENT SIGNATURE (if 12 years or older)

Client name

Signature (type full name)

This consent is stored securely and remains on file for the duration of the therapeutic relationship.