Informed Consent Form

  • Client’s rights: As a client, you have the following rights with regard to Consultation/ Counselling/Therapy:

    • The right to be treated with consideration and respect for personal dignity and autonomy.

    • The right not to be discriminated against for receiving services on the basis of race, ethnicity, age, colour, religion, gender, national origin, sexual orientation, physical or intellectual disability, genetic information, HIV status, or in any manner prohibited by local, state or national laws.

    • The right to confidentiality of communications and personal identifying information within the limitations and requirements for disclosure of client’s information under circumstances such as there is a risk of harm to yourself or others; there is suspected abuse or neglect of a child, elderly, or dependent adult; state and national laws and regulations (required by a court order); or any such situations.

    • Right to ask questions to your counsellor/psychologist/therapist about what to expect during and end of the therapy.

    • Right to decline to proceed to the therapy or to the techniques which may be conducted by the counsellor/psychologist/therapist.

    • Right to let the counsellor/psychologist/therapist know immediately about any concerns such as suicidal thoughts, discomfort, or any such inconvenience during therapy.

    • The right to reasonable protection from physical, sexual, or emotional abuse and inhumane treatment.

    • The right to be informed and the right to refuse any unusual treatment procedures.

    • The rights to have access to one’s own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction.

    • The right to be informed a reasonable amount of time in advance of the reason for terminating participation in a service, and to be provided a referral, unless the service is unavailable or not necessary.

    • Right to discontinue therapy anytime, without any impediment and may return to therapy anytime.

    • The right to know the cost of services.

    • The right to be verbally informed of all client rights, and to receive a written copy upon request.

    • The right to consult with an independent treatment specialist at their own expenses.

    Further, you understand that:

    • You may benefit from counselling/therapy, but the results cannot be guaranteed or assured in case of counselling/therapy. Also, you understand that there are potential risks and benefits associated with any form of counselling/therapy, and that despite our best efforts or the efforts of any such provider, your condition may not improve, and in some cases may even get worse.

    • You may be denied counselling/therapy or any such services provided by us upon non-payment or partial payment of the fee of the service/s being availed by you from us.

    • We may refuse to provide or we may discontinue providing counselling or therapy or any such service to you if the issue you need support with is outside the scope of our therapeutic domains and expertise. In such a case, we may refer you to other therapists or experts who may help you with your issues, though we do not guarantee you with that.

    • In case of a mental health emergency outside of scheduled sessions, you may call 112, or go to the nearest emergency hospital/clinic/centre.

    • The data collected may be recorded (in written and/or audio-visual format) and may be used for supervision, training, and research purposes. Your data and identity will be kept strictly confidential when used for research purposes.

    • In therapist-patient relationships, no gifts will be accepted and no contacts outside therapy will be accepted.

    Important points to remember if availing Tele-counselling/Teletherapy (counselling/therapy through online mode):

    • You understand that “Teletherapy” includes consultation, treatment, transfer, and exchange of medical/Clinical data, emails, telephone conversations, and education using interactive audio, video, or data communications. You also understand that Teletherapy also involves the communication of your mental and/or physical health information, both orally and visually.

    • Unless we explicitly agree otherwise, our Teletherapy exchange is strictly confidential. Any information you choose to share with us will be held in the strictest confidence. Just like our face to face clients, we will not disclose your information to anyone without your prior approval unless we are required to do so by law.

    • You have the right to withdraw or withhold consent from Teletherapy services at any time. You also have the right to terminate treatment at any time. You understand and accept that Teletherapy does not provide emergency services. If you are experiencing an emergency situation, you understand that the protocol would be to call 112 or proceed to the nearest hospital emergency for help.

    • You understand that there are risks and consequences with Teletherapy services including, but not limited to, the possibility, despite reasonable efforts on our part, that: in rare cases, the transmission of your personal and/or clinical information could be disrupted or distorted by technical failures; the transmission of your information could be intercepted by unauthorized persons, and/or the electronic storage of your information could be accessed by unauthorized persons.

    • You understand that while emails/text messages/messages or calls exchanged through social media platforms like- Facebook messenger/WhatsApp/Instagram or so… may be used as forms of communication with us, confidentiality of these platforms cannot be guaranteed due to the complexities and abnormalities involved with the Internet, including, but not limited to, viruses, Trojans, worms, and other involuntary intrusions that have the ability to obtain and disseminate information you wish to keep private.

    • You understand that Teletherapy based services and care may not be as complete as traditional face-to-face services (services provided face-to-face by being present physically). While Teletherapy is a great way to get help with many of life’s problems, overwhelming and potentially dangerous challenges are best met with face-to-face professional support. You understand that Teletherapy is neither a universal substitute, nor the same as face-to-face therapy. If we believe that your needs would best be served by being physically present (face-to-face), we may ask you to come to our service area, or you may be referred to a professional who can provide such services in your area.

    • All the issues which will be discussed in the session will be documented in a file (hard copy or soft copy). For documentation, therapists may record the session in audio or audio-visual format. This information may be accessible to the Hospital/Clinic staff. Clients should ensure that they do not record any audio or audio-visuals of the sessions.

    • You will be responsible for the following: (1) providing yourself with a computer and/or necessary telecommunications equipment and internet access for your Teletherapy sessions, (2) securing or encrypting protected health information transmitted to or stored on your computer/telecommunications device, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for your Teletherapy sessions.

    Undertaking:

    • I/we undertake that I/we have read the details given above (or I/we  have been explained these details in the language understandable to me/us), and I/we give my/our consent with respect to the above mentioned statements.