CONSENT TO TREAT
What is Arammu: The Relationship Checkup
Arammu: The Relationship Checkup is a proactive approach to improving and sustaining the health of our personal and professional relationships. The effectiveness of the Checkup is supported by 20 years of federally-funded research and offers coworkers and couples a fun, annual option for learning about what makes their relationship tick, what their most significant strengths are, and how to address common communication and relationship concerns. The Checkup helps us to tap into what is best about our relationships, increase the quality of our relationship insight, and learn to move with grace, creativity, and humor in our most important relationships.
The Relationship Checkup consists of one 50-minute session with an expert relationship health consultant. Prior to your Checkup appointment you and your partner will complete a brief set of online questionnaires. The questionnaires ask about the quality of your relationship, including your strengths and any concerns that you might have. The completion of the questionnaires should take approximately 10 minutes.
Then you will meet with your relationship health consultant via a video session from the comfort of your own home or work place. During the appointment, your relationship health consultant will spend time getting to know you and your partner, and learn about your relationship. During this meeting you will discuss various aspects of your relationship including your history, your strengths, and any concerns that you might have.
Then, if you choose, you will participate in one final follow-up meeting approximately two weeks later. During this meeting, your relationship health consultant will review your personalized feedback report with research-driven suggestions for maintaining your relationship health and addressing the concerns that you discussed.
Your Annual Checkup
Because the model of the Relationship Checkup is the annual medical exam or annual dental checkup, we will receive a reminder email to schedule your Checkup at the one-year anniversary of your first Checkup.
Will my treatment be kept confidential?
All communications between a relationship health consultant and the individuals with whom the consultant engages in treatment are confidential. Information you provide and the records of your treatment will be kept strictly confidential. No one can find out information about your treatment without your written consent.
The major limitations to this confidentiality occur when there is an immediate threat to life (such as suicide or homicide), when child abuse or neglect is known or suspected or when elder abuse or neglect is known, or when a Court of Law issues a valid subpoena.
Specifically, there are a few circumstances under which the clinician is ethically and legally bound to break this agreement of confidentiality. These are as follows:
1) If the clinician becomes aware that a child under 18 is or has been abused, or a developmentally disabled person or an elderly person is or has been abused, a report must be made to the appropriate authorities.
2) If a participant threatens another person, the clinician must protect the other person by warning the person at risk and reporting the danger to the appropriate authorities.
3) If a participant poses a danger to self or others or is unable to take care of basic needs, the clinician will take appropriate action to protect the participant’s safety including notifying the appropriate authorities.
In addition, your relationship health consultant may consult with their own clinical supervisors about your interviews as part of their own ongoing training. When this occurs, the supervisors will uphold the confidentiality of your interviews to the same degree as your consultant. If you have any questions regarding whom your relationship health consultant will consult regarding her/his work with you, please ask her/him.
You may choose to work with a consultant who is licensed in a different state than where you reside. This will not affect the quality of your treatment. All clinicians have been trained in the Relationship Checkup and have a license to practice. You may ask your consultant what state he/she is licensed in at any time.
Right to discontinue
Participation in this Checkup is completely voluntary. Even if you sign this consent form now, you are not permanently committing yourself. You are free to stop at any time. If you stop, you may request that your data be permanently delete from record.
If you have any questions concerning your consent to participate in the Checkup, you are welcome to contact the Chief Operating Officer, Tatiana Gray: Tatiana@arammu.org.
I have read and understand all the information above and agree to the policies outlined for the Relationship Checkup. By clicking “I Agree,” I voluntarily consent to participate in this activity.