Informed consent


•That Dr Sana Barada, Pharmacologist specializing in addiction studies, will be offering an educational tutoring service regarding the personal well-being conditions of the undersigned based on their request;

•To this end educational tools may be used for the prevention, training and tutoring in the behavioral sector;

•The main service tools will be interviews and teaching sessions which would be done via phone calls, online or in person sessions.

•The fee for the service offered will be agreed between both parties. The undersigned has been informed clearly that the amount paid for the service received cannot be reimbursed. The undersigned has read and agreed to not ask for a refund, even partially, for the cost of the service already performed.

•If I am unable to come to an appointment, I will give 24-hour notice; in the event of not giving notice I will still be obliged to pay the amount agreed upon for the professional service if I did not cancel within the 24 hours prior.

•I am free to withdraw from the service at any time. In order to ensure the best outcome of the same I will inform Dr Sana Barada of my intention to withdraw and make myself available, at my own discretion, to attend a final meeting for the purpose of summarizing the work carried out until that time and I promise to pay the fee for the services/hours received up to that point.

•The specialist is obliged to maintain a serious and professional attitude in carrying out the service.

•There is an agreement between the undersigned and Dr Barada that the tailored educational program will be displayed in a very clear manner in the session following the signing of the following consent.

•The undersigned exempts Dr Barada from any liability related to how they make use of the information received, considering that the given information is purely scientific and does not constitute neither a therapy nor a medical consultation.

•Any dispute arising out of the interpretation or implementation of this agreement and its derivative shall be exclusively subject to Italian law and liability accepted under the jurisdiction of the Italian courts;

•The undersigned has been informed that their personal information is protected by the regulations of GDPR 2016/679 (check the attached document). The undersigned has given their approval to Dr. Barada to see and process their personal information related to the agreed program’s objectives.


In the case of a minor: informed of all this, we (mother and father of the minor) accept that our son/daughter benefits from the service agreed with Dr. Sana Barada


Consolidated form

for professional services

Hereby I/we declare to have been informed of the following points relating to the informed consent:

1.The service offered concerns addiction-related training/tutoring.

2. The service entails addiction-related prevention, training and tutoring activities.

3.In order to achieve the objective, the following instruments will prevalently be implemented:

Interviews and educational sessions.

I/we have been informed about the following points relating to the processing of personal data pursuant to EU Regulation 2016/679:


1.The EU Regulation 2016/679 (hereinafter, the GDPR- General Data Protection Regulation) provides for and reinforces the protection and processing of personal data in the light of the principles of correctness, lawfulness, transparency, protection of privacy and rights of the data subject regarding their data.

2. Dr. Sana Barada is the Data Controller of the processing of the following data collected for the performance of the assignment, subject of this agreement:

a. personal data, contact information and payment details - information relating to the name, telephone number, EPO and PEC address, as well as information regarding the payment of the fee for the assignment (e.g. credit/debit card number), etc.

b. Your personal data may be shared with natural persons authorised by the Data Controller subject to the signing of a confidentiality agreement with medical specialists, third parties, entities or authorities pursuant to the legal provisions.

c. Reasons for the processing: performance of contractual/pre-contractual obligations. The granting of consent is compulsory.


3. Your personal data will be subjected to printed, electronic and/or automated processingmethods, therefore in both manual and computerised node. In any case, all appropriate measures will be adopted in order to protect their confidentiality, in observance of the regulations in force and professional secrecy.

4. Appropriate security measures will be taken to guarantee the protection, security, integrity and accessibility of your personal data.

5. Your personal data will only be stored for the time strictly necessaryfor achieving the purposes for which they have been collected or for any other connected legitimate purposes.


6. Personal data that is no longer necessary, or for which there is no legal requirement for its relative storage, will be rendered irreversibly anonymous or destroyed in a secure manner.


7. The storage times, in relation to the different purposes listed above, will be as follows:

a. Personal data, contact and payment details will only be stored for the time strictly necessary for fulfilling the contractual/accounting obligations and subsequently for a period of 10 years;

b. Data relating to health conditions will only be stored for the time strictly necessary for performing the assignment and achievement of the purposes of the same, and in any case, for a minimum period of 5 years (art. 17 of the Code of Ethics of Italian Psychologists).


8. The list of data processors and any third-party subjects to whom or to which the data are communicated can be viewed on request.


9. In the event of the continuation of certain conditions in relation to the specificities connected to the performance of the assignment, it will be possible for the data subject to exercise the rights referred to in articles 15 to 22 of the GDPR (such as the right to access to personal data, the right to rectification, erasure, and restriction of the processing, the right to receive the personal data concerning him or her in a structured, commonly used and machine-readable format, as well as the right to transmit said data to another data controller).

Having examined and understood everything indicated above on my/our own behalf.

In case of a minor, having examined and understood all of the above in exercising parental responsibility on the minor,


Having received the relative professional information and all appropriate data regarding the purposes and methods of the same, I/we hereby give my/our own free consent.


Having received the relative information regarding the processing of personal data and in relation to everything indicated above regarding the processing and communication of my/our own personal data for the purposes indicated in this statement, I/WE GIVE MY/OUR CONSENT.

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