Referral Form- Child/Young Adult

Please fill the referral form with the information that you have available. Kindly attach any additional
information that will aid the referral process.

About the Child/Young Person Date:

Child/Young person’s name:

Aadarsh gavyi
Address:

Child/Young person’s Email ID:

Child/Young person’s mobile no: Date of birth: Age:

Gender: MaleLanguage: Indian Nationality:

Name & address of current school/college: Ashok nagar secondary marathi school
Current grade: 9th
Telephone number of current school/ college:

Reason for Referral

Please provide details of the concerns for which the referral is being made, including significant history:

Are any of the following a concern/risk for the child/young person? (Past or present)

Communication problems Depression/Emotional disorder

Anxiety Attention/Focus concerns

Alcohol/Drugs Autism spectrum disorder Family conflict

Parenting concerns Hearing voices/Seeing things Concerns with peers
Bereavement Physical disabilities Trauma history

Eating concerns Other:

Please provide details:

Please describe any safety concerns for the child/young person

Deliberate self-harm
Domestic violence Harm to others

Suicidal thoughts Other:

 Has the child/young person been suffering from any physical health concerns/prescribed any medication?
If yes, summarize:

Has the child/ young person been previously diagnosed with mental health concerns/prescribed any medication?
If yes, summarize:

Please list other agencies/professionals involved currently/in the past with the child/young person
(e.g., paediatricians, psychiatrists, counsellors, psychologists, speech and language therapists, occupational therapists,
nutritionists, etc.)

About the Family

Type of Family:

Nuclear Joint Separated Divorced Blended

Mother’s name: Email ID:

Phone no: Educational qualification:

Nationality:
Occupation:

Father’s name: Email ID:

Phone no: Educational Qualification:

Occupation: Nationality:

If parents are not the primary caregivers

Guardian’s name: Email ID:

Phone no: Educational qualification:

Occupation: Nationality:

Child/Young person’s siblings:

Name Age Nursery/School/College

Is there a history of mental health concerns in the family? If so, please provide details.

Has the child/young person/family been previously involved with Mpower? If so, name of the client:

Where did you hear about us?

Classmate Mpower website Teachers
Posters Mpower social media Other:

Would you like to be informed about Mpower workshops,programmes, seminars, e-groups and parent groups?
Yes No
 Policy for Parents/legal Guardians/Nominated Representatives of a Minor Client

The following (read along with the full terms and conditions sent to you vide our confirmation email) forms the legal under-
standing (“Terms”) between Aditya Birla Education Trust hereinafter referred as “Mpower” (and which expression shall mean
and include its trustees, officers, employees, agents or any of its representatives) and the Client/NR:

1. Sessions at Mpower will be conducted between you (“Client”)/your nominated representative (“NR”) and a “Therpist/
Psychiatrist” specifically to address the Client’s mental health concerns (“Services”). The client and Mpower come to
an agreement about the goals of treatment, treatment procedures, and a regular schedule for the time, place and
duration of their treatment sessions. The Client has been informed that he / she will be assisted with Sessions that
are aimed to help people experiencing significant emotional distress that is coming in the way of them being physical
ly well, enjoying personal relationships or working productively. The Client understands that the psychotherapist /
Psychiatrist contacted during a set appointment would evaluate his / her need and context and guide him / her about
the most suitable option for intervention in that context (tele psychotherapy/ in-person psychotherapy/ crisis inter
vention/ emergency services) it begins with the therapist understanding the background of the person seeking help
and the concerns that led them to seek help. The Client expressly agrees to conduct of Online Sessions by Mpower on
available video meeting platforms in place of regular face to face Sessions at Mpower, in case of situations not
permitting or rendering difficult, the conduct of face to face Sessions or as and when otherwise mutually agreed
between the Cleint and Mpower considering benefits of the Online Sessions to the Client (e-malis permitted). The
Client /NR understands that Online Sessions on Video meeting platforms has its own limitations as compared to in
person sessions and some details could potentially be missed out despite the Therapists / Psychiatrists best efforts.
With due knowledge of such limitations the Client /NR expressly consent to the Online Sessions on Video meeting
platforms. Client understands that Mpower may also temporarily stop or discontinue these Online sessions/recom
mend any other method or line of treatment if either of us experience any difficulty in the process and in my best
[Link] Client / NR agrees to avail Therapy / Counselling Sessions on Audio / Video through Phone / mobile / online
platforms. The Client /NR understand that Therapy / Counselling on Audio / Video has its own limitations as compared
to in person sessions and some details could potentially be missed out despite the Therapists / Psychiatrists best
efforts. With due knowledge of such limitations the Client /NR expressly consent to the Therapy / Counselling
Sessions on Video / Audio.

2. The Client/parent/guardian/NR represents that they understand and agree to the Terms. Minor clients
should be accompanied by a parent/guardian/NR at all times while at Mpower.

3. Crisis:
Mpower is not a crisis centre and has finite operating hours. If the Client’s situation involves a life-threatening emer
gency and / or Client Sessions, Records, and Confidentiality: requires urgent physical care, the Client must visit a
hospital for assistance.

4. Client Sessions, Records, and Confidentiality:

a. Clients and / or their parents / guardians / NRs are required to present a photo ID/ photo of the client, of which a
photocopy will be taken for Mpower’s records, before starting the screening session. “Client Information ” means all
information provided by the Clients / parents / guardians / NRs to Mpower and / or the Therapist / Psychiatrist,
including all medical health records, personal information, sensitive information, records of the sessions, and any
communication between the Therapist/Psychiatrist and the Clients/parents/guardians/NRs. Written documentation
of the Client Information includes a referral form, notes from initial screenings, a provisional diagnosis, a treatment
plan, goals and recommendations, and progress notes for every visit.
b. The Clients/parents/guardians/NRs consent to the use and retention by Mpower of the Client Information for a
minimum period of 5 (Five) years from the date of services last rendered. Mpower shall at its discretion destroy Client
information unless the Client expressly requests in writing to retain the Client information for a further period.
c. Mpower will take best efforts to keep the Client Information, including communication between the Client and
Therapist / Psychiatrist at Mpower during the session confidential. The Clients/parents/guardians/NRs are entitled
to access their basic medical health record (which includes demographic information, diagnosis, and treatment plan)
by requesting it in writing from Mpower. Subsequent details and further records will be given as per needs of appro
priate legal directives at that time.
d. Mpower may retain Client Information for the purpose of analysis and research. Our professionals may internally
share certain Client Information for therapeutic purposes, clinical purposes, intern education, data analysis, or for
research purposes, as well as during multidisciplinary meetings.
e. Confidentiality is of utmost importance whilst sensitively dealing with each of our Clients/NRs and their families.
However, disclosure of Client Information is mandatory in the event of any perceived risk to the Client or from the
Client, or for any reason as may be necessary to disclose by law.
f. Mpower does not permit the audio and / or video recording of any Service at the Centre.
g. For Online Sessions its shall be in the Clients responsibility to ensure that the Sessions are availaed in a closed and
 private space ensuring all security for hardware, software, internet connection etc. at its end. The Client / NR
understands that a third party Video meeting platform will be used for online Sessions as per the terms and conditions
of use of the said onlineplatform. Client / NR hereby agrees not to hold Mpower, its Psychologist, Psychiatrist,
Employees, agents and affiliates for any breach in security in technology or breach of confidentiality due to Sessions
conducted on Video meeting platforms..

5. Length and Frequency of Sessions:

The length of the first screening intake sessionis upto 45 to 60 minutes. The standard length of subsequent ongoing
sessions is 45 minutes. To avail of the Services for more than 45 minutes, Client/parent/guardian/NR will be required
to book a separate appointment for a new session. Frequency of sessions is decided according to the needs and the
unique situation of each Client. We generally suggest starting counselling with regular weekly appointments. Once
some progress has been made, visits may be less frequent and spaced out over a larger period of time.

6. Being Late for aSession:

a. If the Client arrives or connects late for an appointment, the duration of the appointment may be shortened by the
amount of time the Client came in late. When the Client arrives, the Therapist/Psychiatrist will make use of the time
that is available, and may not be able to extend the session time due to the next Client’s appointment.

7. Right to Deny Service:

a. Mpower reserves the right to deny or discontinue Services with the Client, incase the Client and /or parent/guard
ian/NR misbehaves or misconducts or mistreats any personnel of Mpower or any person/staff associated with Mpower
or creates an unhealthy atmosphere in the vicinity of Mpower which is likely to affect the goodwill of Mpower.
b. Mpower may cease to provide Services to the Client, if a referral is made to inpatient treatment by Mpower Therapist/
Psychiatrist, and the Client/parent/guardian/NR refuses that referral. Mpower may also cease to provide Services to
the Client if Services at Mpower are deemed non-beneficial to the Client by Mpower Therapist/Psychiatrist for any
particular reason.
8. DISCLAIMER:
a. Mpower shall take reasonable care in conducting its activities which are a part of Mpower’s programme.
b. Mpower accepts no responsibility of any nature whatsoever for any injury, damage or loss caused during the course of
its activities to its Client. Mpower does not take any responsibility towards personal safety of the Client. The
Client/parent/guardian/NR warrants and certifies that:
c. Clients/parents/guardians/NRs is absolutely responsible for the safety and care of the Clients during their sessions at
Mpower;
d. In case of any physical difficulty or injury to the Client, the Client/parent/guardian/NR will immediately inform the
Therapist/ Psychiatrist/Front Desk of Mpower.
e. The Client//parent/guardian/NR agrees to accept full responsibility for Mpower’s actions while using the facilities
provided by Mpower. Clients/parents/guardians/NRs agree that Client’s participation is entirely at the
Client/parent/guardian/NR’s risk and further agrees that Mpower shall not be liable for any personal injury, loss or
damage caused to the Client during visit to Mpower.
f. The Client acknowledges that referral to Mpower can be made by parents/guardians/NRs, general practitioners or any
other caregivers of theClient.
g. The Client/parent/guardian/NR agrees that the Client Information, including any personal information or sensitive
personal information as provided by the Client/parent/guardian/NR has been submitted in the registration form with
the Client/NR’s express consent.
h. The contents of this form have been explained to the Client / NR in a language that they understand. After
reading/listening to and understanding all of the above, the Client / NR hereby expressly consent for face to face and
online sessions via video meeting platforms, by Mpower, as per the terms and conditions as hereinabove mentioned,
without having been subjected to coercion, undue influence or intimidation to undertake treatment at Mpower, after
adequately understanding and considering the information and procedure for undergoing treatment alongwith an
understanding of anticipated risks involved, if any. The Client / NR understand that they have the freedom to withdraw
from these sessions at any time they wish. The Client understands that the psychotherapist / Psychiatrist at Mpower
would use their professional discretion to provide required recommendations about the type of professional service
that may be required at any given point of time. Hence, the Client / NR shall not hold Mpower liable for any adverse
events, such as lack of improvement, deterioration or situations of potential risk of harm to self or others or for any act
or omission which shall directly or indirectly affect the health of the Client. The Clients/parents/guardians/NRs agree
to defend, indemnify and hold harmless Mpower, from and against allliabilities, claims,or losses, and acknowledge that

Mpower cannot be held liable for any claims, arising out of use of the Services, violation of the Terms or violation of
any third party right.
i. These Terms shall be governed by the laws of India and any disputes arising out of the Terms shall be subject to the
exclusive jurisdiction of the courts of Mumbai.
j. I understand that Mpower is not liable for any harm to the Child, whether self-inflicted or not, inside or outside the
premises of Mpower.
k. I undertake and acknowledge that Mpower (including its representatives, employees, staff, psychiatrist, psychologists)
shall not be liable for any actions, including any attempt to commit suicide, medicalim pairment or death of my Child,
whether within the premises of Mpower, orinany other place.
l. I understand and acknowledge that if my Child requires medical intervention while present in MPower’s premises, Mpower
may request me or any other legal guardian of my Child as authorized by me, to take the Child to an in-patient psychiatric
facility, hospital, medical centre or medical establishment (“Medical Facility”). If Mpower determines that there is a medi
cal emergency or if the Child is reluctant to leave with me or the legal guardian, I authorize Mpower to call an ambulance
and shift the Child to a Medical Facility. I hereby authorise Mpower and its personnel to take such steps as it may deem
fit and necessary to obtain medical care for my Child, or to transport my Child to a Medical Facility.
m. I acknowledge that I shall be responsible for the safety of my Child at all times and that any assistance/help if provided
by Mpower and the Medical Health Professionals beyond the consultancy services for which Mpower is being engaged,
would be provided only on humanitarian grounds. I Further acknowledge that by providing such assistance/help Mpower
and the Medical Health Professionals do not assume any responsibility for the safety of my Child, which responsibility
shall solely be mine.

Client/Parent/Guardian/Nominated Representative Consent:

I, ________________________________________________________________ [parent/guardian/NR of ______,

hereby declare that all information or details provided by me are accurate/verified and true to the best of my
knowledge. I also give my consent to the Mpower professionals to use this information for therapeutic assessments and interven-
tion in the best interest of the Client. hereby declare that all information or details provided by me are accurate/verified and true
to the best of my knowledge. I also give my consent to the Mpower professionals to use this information for therapeutic assess-
ments and intervention in the best interest of the Client.

I agree to the above terms & conditions:

Place:________________________ Date:_________________________

Signature:__________________