STATEMENT OF INFORMED CONSENT

I, THE UNDERSIGNED

HEREBY DECLARE

  1. I accept that Roland Bal will provide counseling to assist resolving my trauma and/or post-traumatic stress disorder. I understand that Roland Bal is NOT a conventionally qualified medical practitioner and I accept that his training and qualifications are bone fide in the field for online counseling.
  2. For the purposes of the above, I hereby give my informed consent for Roland Bal to collect, obtain, write down, store, process and use my personal data. I understand that doing so would help Roland Bal to provide an accurate as possible, full scope advice on the issues raised. I recognise and accept that such personal data may include my name, date and place of birth, address, e-mail, as well as any health data relating to my foregoing and current mental health status quo.
  3. I am made aware that such data is only to be collected for the purposes of counseling and will only be kept, read, used and accessed by Roland Bal only.
  4. I confirm that I have been informed of the relevance and purpose of any treatment procedures which my practitioner, Roland Bal, may undertake, and that I hereby give me consent thereto.
  5. I acknowledge that I currently do not have active psychotic episodes or suicidal tendencies. I acknowledge that online counseling may be contra-indicative in such, or similar, cases.