Therapy Informed Consent Form

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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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Introduction

Therapy is the process of resolving psychological problems, beliefs, and feelings of a person. It requires trust and confidence between the client and the therapist.

The client should know his or her rights as well as the responsibilities for therapy. This informed consent should be able to explain the scope and limitation of this therapy including the rights and responsibilities of the parties to a therapy.

If you have questions, please do let us know and we will be happy to answer them.
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Unless there is an emergency, all the therapy sessions are private and confidential with the exception of specific exceptions described below:

Child, elder or dependant abuse,

Expressed threats of violence toward an ascertainable victim,

Detailed planning or concrete signs of future suicide attempts,

Sharing information is necessary to facilitate client care across multiple providers,

Sharing information is necessary for the treatment,

Requests from legal and administrative institutions

With the Client’s prior written consent, the Counsellor may legally speak to another healthcare provider or Client’s family members in emergency situations. The Client may direct the Counsellor to share information with whomever the Client desires, and the Client may change his/her mind anytime and revoke the permission.

The Counsellor is allowed to keep brief notes of the therapy session which shall be kept in strict confidence.

Therapy is not to give any advice. Therapy involves presenting clients with various perspectives, allowing them to make their own choices.

The Client may ask questions on what to expect during and end result of the therapy.

The Client may cease to continue therapy anytime, without any impediment and may return to therapy anytime.

The therapist has the right to dismiss the Client from the course of therapy.

To ensure ethical standards and optimize therapy effectiveness, clients avoid contacting their therapist outside of scheduled therapy sessions.

DO NOT USE THIS SERVICE IN CASE OF ANY LIFE-THREATENING SITUATION. USE THESE RESOURCES – https://en.m.wikipedia.org/wiki/List_of_suicide_crisis_lines OR GET IN-PERSON HELP IMMEDIATELY
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Cancellation policy

Payment must be made in advance. Clients may cancel sessions up to 24 hours beforehand. No refunds will be provided for cancellations after this window.
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CONSENT

By filling out this informed consent form I affirm that:

I have read the information about the therapy above and have understood them very well.

I have had the opportunity to ask questions regarding the therapy that I will take as well as other information about the therapy and all of which have been answered by the therapist and to my satisfaction.

I understand my rights as well as my responsibilities as a client/patient to this therapy.

Following all the understanding above, I hereby give my full consent to the foregoing Counselling.
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Age of consent* This field is required.
I am of legal age and I voluntarily enter this agreement with full knowledge and competence.
I am a minor. However, my parent/guardian gives his/her full consent for my foregoing treatment.
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Client Name* This field is required.
First Name
Middle Name
Last Name
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Emergency Contact Name * This field is required.
First Name
Last Name
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Emergency Contact Number* This field is required.
Area Code
Phone Number
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Signature* This field is required.
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Date* This field is required.
Date
Month
Day
Year
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Legal Guardian Name* This field is required.
First Name
Middle Name
Last Name
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Signature* This field is required.
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