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Consent Form Reference

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rashipsych
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3 views

Consent Form Reference

Uploaded by

rashipsych
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NAME

Educational background
EMAIL; location ; Number

Informed Consent Form


The following document contains all necessary information regarding psychotherapy and the
psychotherapeutic process with the therapist. Please read it carefully and in case of doubt,
contact the therapist for further clarifications.

About The Therapist


- Introduce yourself, your approach, the age group you feel comfortable taking on,
concerns.
The Therapeutic Process
- Describe the therapeutic process according to your approach
Supervision Clause
is taking therapy sessions under supervision from experienced psychologists at
“AnamKaaRuh Therapy Care and Counselling”. The supervision process includes guiding,
navigating and helping each other and trainee therapists in this journey of counselling
services. However, the identity and the identification details of the client during supervision
remain confidential.

Privacy and Confidentiality


Mention privacy and confidentiality clause and exceptions to it

Duration and fees of the Sessions

∙ The durations of the sessions will be 50 minutes long only. It is the client’s
responsibility to join in on time. The counselling sessions are on a pro-bono basis, i.e.
free of cost for the first 6 sessions and then a minimal charge would be applied
___ (mention a charge less than 500 that you want to charge).

- Add other policies/guidelines- where sessions would be conducted/ your


availability, how to reach out/ business hours/

Rescheduling and Cancelling Clause


- Your reschedule and cancellation policies
Steps To Follow In Case of Mental Health Emergency
- Add how this is not a high risk service.

Consent
I have reviewed the counselling consent form carefully and understand it completely. I
consent to seeking therapy and voluntarily signing the agreement.
Name of client:
Pronouns:
Age:
Contact Number:
E-mail:
Date:

Emergency Contact 1 (Mandatory)


Name:
Contact Number:
Relationship with the client:

Emergency Contact 2
Name:
Contact Number:
Relationship with the client:

Guardian (Mandatory for under 18 years)


Name:
Contact Number:
Relationship with the client:

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