知 情 同 意 书

Informed Consent

 

请您将这份知情同意书打印出来，阅读、填写，并携带前来。 Please print, read, fill out and bring forms to your session with you.

 

本协议旨在向您（“来访者”）提供与工程幸福（“咨询师”）的实践、执行和程序相关的重要信息。它详细说明了隐私保护、来访者权利和规定，并就咨询师如何以咨询、付款和运营为目的使用和处理您的个人信息进行了详尽解释。

This agreement is intended to provide you (“the Client”) with important information regarding the practices, polices and procedures of Engineering Wellbeing (“the Practice”). It details privacy protections, client’s rights and provisions, and explains how this Practice uses and handles your personal information for the purpose of counselling, payment and operations.

 

 

背景和资质

Background and Qualifications

 

工程幸福（Engineering Wellbeing）是一家在中国注册的公司，注册名称为北京罗钦心理健康咨询有限公司。工程幸福的主要目的是为来访者提供职业的或非职业的自我提升方案（“咨询时段”）。心因性或功能根源的问题只通过心理或医疗转诊进行治疗。

Engineering Wellbeing is a counselling company registered in China under the name 北京罗钦心理健康咨询有限公司. The major purpose of Engineering Wellbeing is to propose programs for vocational or avocational self-improvement (“counselling session”). Problems of psychogenic or functional origin are treated by psychological or medical referrals only.

关于保罗·罗钦博士的背景资质，请阅读官网中的专家介绍。

Please read more about Dr. Paul Rochon’s background and qualifications from the website.

 

关于咨询师张旋的背景资质，请阅读官网中的专家介绍。

Please read more about Zoe Zhang Xuan’s background and qualifications from the website.

 

 

风险与受益

Risks and Benefits

 

咨询服务是一个过程。过程中，咨询师和来访者将讨论无数的问题、事件、经历、感受和记忆，目的是为来访者创造积极的改变，使来访者能更充分地体会他的生活。过程中，来访者将有机会去更好、更深入地了解自身变化，以及可能遇到的困难。咨询需要来访者和咨询师的共同努力。其进展和成功可能因所处理的具体问题/难题以及许多其他因素而异。

The counselling service is a process in which the Practice and the Client discuss myriad issues, events, experiences, feelings, and memories for the purpose of creating positive change so the Client can experience his life more fully. It provides an opportunity to understand better, and more deeply the dynamic, as well as any difficulties the Client may be experiencing. The consulting is a joint effort between the Client and the Practice. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors.

咨询可能会给来访者带来许多成效，包括但不限于，恢复睡眠模式，提高注意力，克服压力和焦虑，减少消极思想和自我伤害行为，改善人际关系，增加在社交、工作和家庭环境中的舒适度，增强亲密关系的能力，增加自信。达到这些成效也需要来访者的大量努力，包括在过程中积极参与，诚实，并有意愿去改变感觉、思想和行为。我们不能保证咨询服务将产生上述所列的任何或全部成效，但咨询师承诺将使用其所有专业知识、经验和技能，帮助来访者在尽可能少的咨询时段内实现其目标。

The counselling may result in a number of benefits to the Client, including, but not limited to, restoring the sleep pattern, increase focus, overcoming stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviours, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. Such benefits may also require substantial effort on the part of the Client, including active participation in the process, honesty, and a willingness to change feelings, thoughts and behaviours. There is no guarantee that counselling will yield any or all of the benefits listed above, but the Practice promises to use all expertise, experience and skill to help the Client achieve his goals in the least amount of sessions possible.  

咨询也可能涉及一些不适，包括回忆和讨论不愉快的事件、感受和经历。过程中可能会唤起强烈的悲伤、愤怒、恐惧等情绪。有时，咨询师可能会挑战来访者的认知和假设，并提供不同的视角。来访者提出的问题可能会导致意想不到的结果，包括个人关系的变化。来访者应注意，任何关于其个人关系状态的决定，都是来访者的责任。

The counselling may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. The process may evoke strong feelings of sadness, anger, fear, etc. There may be times in which the Practice will challenge the Client’s perceptions and assumptions, and offer different perspectives. The issues presented by the Client may result in unintended outcomes, including changes in personal relationships. The Client should be aware that any decision on the status of his personal relationships is the responsibility of the Client. 

在咨询过程中，许多来访者发现他们在感觉变好之前，可能会先感觉更糟了。这种情况通常是正常的。个人的成长和改变有时是容易和迅速的，但也可能缓慢且令人沮丧。来访者应和咨询师一起解决过程中的任何困扰。

During the process, many Clients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times, but may also be slow and frustrating. The Client should address any concerns he has regarding his progress with the Practice.

 

 

保密性

Confidentiality

 

除法律规定或许可的情况外，未经来访者书面授权，来访者披露的信息通常视为保密信息，且不会向任何第三方披露。保密的例外情况包括但不限于，举报对儿童、老年人和无自理能力成年人的虐待，当来访者对可识别的受害者进行严重暴力威胁，或者来访者对自己或他人的人身或财产构成危险时。

The information disclosed by the Client is generally confidential and will not be released to any third party without written authorization from the Client, except where required or permitted by law. Exceptions to confidentiality, include but are not limited to, reporting child, elder and dependent adult abuse, when a Client makes a serious threat of violence towards a reasonably identifiable victim, or when the Client is dangerous to himself or the person or property of another.

有些来访者可选择在他们的咨询中使用通讯设备。这包括但不限于通过 Zoom、Skype、微信、电话、电子邮件、信息或聊天进行的在线咨询。由于在线咨询的性质，总是存在未经授权的人试图去发掘您个人信息的可能性。咨询师会采取一切预防措施，来保障您资料的安全；但无法保证未经授权查阅网络通讯的情况不会发生。对于在线咨询中使用的任何技术设备的授权和未授权的访问，建议您采取预防措施。此外，要注意任何可能会接触到您电脑、手机或咨询中所用设备的朋友、家人、其他重要人士和同事。

Some Clients may choose to use technology in their sessions. This includes but is not limited to online counselling via Zoom, Skype, WeChat, telephone, email, text or chat. Due to the nature of online counselling, there is always the possibility that unauthorized persons may attempt to discover your personal information. The Practice will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in online sessions. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your sessions. 

 

 

记录留存

Record Keeping

 

咨询师可保留您的治疗记录。保存这些记录是为了帮助维持您咨询的方向和服务的连续性。这些记录是咨询师的唯一专有财产。除在保密部分讨论的保密性限制外，它们是不会被共享出去的。如果来访者希望公开他们的记录，他们必须签署一份信息公开声明，其中指明将向哪些人发布哪些信息。记录将保存至少 5 年，但也可能保存更长时间。记录将以电子形式保存在数码存储设备中，或以纸质文件形式保存在上锁的柜子内。

The Practice may keep records of your sessions. These records are kept to assist in maintaining the direction of your sessions and continuity of service. Such records are the sole property of the Practice. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the Client wish to have their records released, they are required to sign a release of information, which specifies what information is to be released and to whom. Records will be kept for at least 5 years but may be kept for longer. Records will be kept either electronically on a digital storage device or in a paper file and stored in a locked cabinet.  

 

大多数情况下，咨询师会以电子形式来处理您的相关信息。因此，如有发布需要，可保留权利只以电子形式提供所有有关资料。

The Practice operates predominantly on information in electronic form. As such, it reserves the right, where such release is required, to provide all such information in electronic form only.  

 

 

费用说明

Fee Arrangements

 

保罗·罗钦博士的费用标准，请以本官网为准。

Please reference Dr. Paul Rochon’s fee standard from the website.

根据通常和惯例，保罗·罗钦博士的咨询时长是50分钟。咨询时段超过50分钟的，按比例收取多出时间的费用。咨询师保留定期调整此费用的权利。

The usual and customary time for a counseling session is 50 minutes by Dr. Paul Rochon. Sessions longer than 50 minutes are charged for the additional time pro rata. The Practice reserves the right to periodically adjust this fee.

 

咨询师张旋的费用标准，请以本官网为准。

Please reference Zoe Zhang Xuan’s fee standard from the website.

根据通常和惯例，张旋女士的咨询时长是60分钟。咨询时段超过60分钟的，按比例收取多出时间的费用。咨询师保留定期调整此费用的权利。

The usual and customary time for a counseling session is 60 minutes by Zoe Zhang Xuan. Sessions longer than 60 minutes are charged for the additional time pro rata. The Practice reserves the right to periodically adjust this fee.

 

如有任何调整费用，来访者会被提前告知。每次预约时间前，来访者须以现金或银行转账形式支付全部费用。其他服务费用可随时向咨询师进行问询。

The Client will be notified of any adjustment fee in advance. Payment is required in full prior to each appointment via Cash or Bank Transfer. Other services fees are available any time by asking the Practice.

 

基本存款账户信息 

Basic deposit account information

账户名称 account name: 北京罗钦心理健康咨询有限公司

账户号码 account number: 110941909110301

开户银行 Bank Name: 招商银行股份有限公司北京分行工体支行

 

 

合同的取消

Cancellation

 

如来访者错过任何咨询，其有责任支付已商定的费用。如来访者未能提前 24 小时通知咨询师取消咨询，其亦有责任支付该时段商定的费用。来访者有权取消咨询，但必须在预约时间开始前至少 24 小时通过给 contact@engineeringsleep.com 发送电子邮件的形式通知咨询师。

The Client is responsible for payment of the agreed upon fee for any missed session(s). The Client is also responsible for payment of the agreed upon fee for any session(s) for which The Client failed to give the Practice at least 24 hours notice of cancellation. To exercise the right to cancel, the Client must inform the Practice via email to contact@engineeringsleep.com at least 24 hours before the start of the appointment. 

如果来访者迟到超过十分钟，会议可被取消而不退款。

If the Client is more than ten minutes late to his appointment, the session may be cancelled without a refund.

如果咨询师需要取消预约，无法执行服务或意外延误超过十分钟，将提供全额退款或选择重新安排到另一个时间。

If the Practice needs to cancel the appointment, is unable to perform the service or has an unexpected delay for more than ten minutes, a full refund will be offered or the option of rescheduling to another time.

 

 

线上咨询

Online Sessions

 

来访者必须确保进行咨询的环境是安全的、不受干扰的，如有其他人在场或监视咨询过程，来访者必须通知咨询师。如咨询师确定预约的咨询不是为了接受咨询为目的，而为了其他目的，则咨询师可以不经告知而终止咨询。如果发生这种情况，来访者将继续承担所有的咨询费用。

The Client must ensure that the environment in which sessions are undertaken will be safe and free from distractions and to inform the Practice if there is anyone else present or monitoring the session. The Practice may terminate the session without warning if the Practice should determine that the session has been booked for some purpose other than to receive the counselling session, and that should this occur, the Client will remain liable for any session fee.  

来访者必须提供备用手机号码或在通讯设备故障时的短信联络，以及第三方紧急联系电话的号码。来访者必须清楚地知道，当服务商/电脑故障或其他通信中断的情况下该如何处理。如有必要，请设一个闹钟，以防来访者在咨询过程中睡着或处于催眠状态，以致在咨询结束时没有反应。

The Client must give a back-up number or text arrangement in case of technology failure, and a third-party emergency contact number. The Client must have a clear understanding of what to do in the event of server or computer breakdown or other loss of communication. Please, set an alarm clock if necessary, just in the unlikely event that the client falls asleep during the session or is so deep in hypnosis as to be non-responsive at the session’s conclusion.

来访者最好不使用智能手机，以至于在咨询过程中总是需要手持。建议使用平板电脑、笔记本电脑或台式电脑进行在线咨询，带有内置摄像头和麦克风即可。

It is best to use a tablet, laptop or computer for the online session rather than a smartphone – something that won’t require the Client to hold it. A webcam and microphone – built in ones are fine.

没有必要为在线咨询打造完美的、安静的环境。不过，最好找一个受到其他家庭成员和宠物干扰最小的房间，并确保来访者已关闭手机和电脑上的所有应用程序。

It is not necessary to create the perfect ambient, peaceful setting for an online session. It would be beneficial, however, to find a room with minimal disturbance from other household members and pets, and to ensure the Client has turned off the mobile and all apps on the computer.   

来访者可以找一个能舒服坐着的地方，并且咨询师能通过电脑摄像头清楚地看到您。来访者需要保持被看到和舒适的状态。

Find somewhere the Client can comfortably sit down and where the Practice will be able to see clearly via the computer’s camera. The Client needs to be visible and comfortable.

 

 

终止服务

Termination

 

咨询师保留酌情终止服务的权利。终止的原因包括但不限于：未及时支付费用、未能遵守建议、利益冲突、未能参与项目、来访者的需求超出了咨询师的能力范围，或来访者没有取得足够的进展。来访者有权酌情终止咨询。一旦任何一方决定终止项目，咨询师通常会建议来访者参加至少最后一次或可能多次的“终止咨询”。这（几）次咨询旨在提供积极的结束体验，并让双方有机会反思已经完成的工作。咨询师还将通过向来访者提供转诊服务，努力确保其顺利过渡到另一位咨询师那里。

The Practice reserves the right to terminate the services at his discretion. Reasons for termination include but are not limited to, untimely payment of fees, failure to comply with recommendations, conflicts of interest, failure to participate in the program, Clients’ needs are outside of the Practice’s scope of competence, or the Client not making adequate progress. The Client has the right to terminate the counselling at his discretion. Upon either party’s decision to terminate the program, the Practice will generally recommend that the Client participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. The Practice will also attempt to ensure a smooth transition to another Practice by offering referrals to the Client.  

 

 

合同的确认

Acknowledgement

 

来访者在下方签字，即表示其已审阅并完全理解本协议的条款和条件。来访者已与咨询师讨论了这些条款和条件，而且咨询师对来访者有关条款和条件的任何问题给出了满意的答复。来访者同意遵守本协议的条款和条件，并同意参与该咨询师的咨询。此外，来访者同意咨询师免于因该服务可能导致的任何伤害、并发症甚至过失而引起的任何索赔、要求或损害赔偿诉讼。

By signing below, the Client acknowledges that he has reviewed and fully understands the terms and conditions of this Agreement. The Client has discussed such terms and conditions with the Practice, and has had any questions with regard to its terms and conditions answered to the Client’s satisfaction. The Client agrees to abide by the terms and conditions of this Agreement and consents to participate in the counselling session with the Practice. Moreover, the Client agrees to hold the Practice free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, even negligence, that may result from such service.  

 

来访者 Client  __________

日期 Date _____________      

 

工程幸福 Engineering Wellbeing  __________

日期 Date ___________