Informed Consent for Psychotherapy

Welcome: Before starting your therapy, it is important to know what to expect and to
understand your rights as well as commitments. This consent form is an attempt to
be as transparent with you as we can about the therapy process so you are fully
informed prior to starting your journey.

Psychotherapy is a way to help people experiencing significant emotional distress

that is coming in the way of them being physically well, enjoying personal
relationships or working productively. Psychotherapy begins with the therapist
understanding the background of the person seeking help and the concerns that led
them to seek help. Following this, the client and psychotherapist 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.

Clinic Description: Therapists at AB hold a variety of degrees and certifications in the

field of psychology. The AB Clinic offers services to children, adolescents, and
adults. Every effort is made to provide the highest quality of services and, when
required, to provide appropriate referrals to other resources.

Counselling Approach: Therapists at AB Clinic draw on a variety of different

theoretical orientations, approaches, and techniques while working with clients.
Operating from a humanistic and cognitive-behavioural orientation to counselling
and therapy. If you’d like to know more about any of the approaches, you can ask
questions about them or read more on our website at www.abclinic.com.

Throughout the course of the therapy, the therapists will do their best to explain to
you the approaches being used and the rationale for any interventions.
Psychotherapy works best when there is open communication and collaboration
between the therapist and the client, and that includes sharing thoughts and feelings
about the therapeutic experience itself.

Length of Therapy: Once we have agreed to work together, we will schedule one
appointment every 1-2 weeks as we can agree upon it. The session length will be 50
minutes. On average, many people feel that they have obtained what they were
looking for in 8-25 sessions. For some, it is fewer, and for others, it may be longer.

Possible Benefits and Risks: Although no guarantees can be made as to the

outcomes of taking psychotherapy, research and clinical experience do indicate
commonly reported benefits and challenges. Psychotherapy has been shown to have
numerous possible benefits for those who engage in it, including the alleviation of
particular symptoms and a reduction in levels of distress and suffering; improved
flexibility in ways of being and relating to others and improved effectiveness in
interpersonal relationships; the attainment of particular goals set in therapy; and
finding solutions to problems that you are facing.

Confronting challenges in yourself and your life and making changes can sometimes
be an anxiety-provoking experience. In addition to the positive changes and benefits
that you may experience, engaging in psychotherapy can bring up uncomfortable
emotions such as sadness, guilt, fear, anger, grief, or uncertainty. It’s also possible
that undergoing the changes produced in psychotherapy may affect your
relationships with others, including friends, coworkers, and family members who
may or may not be supportive or welcoming of these changes.

The process of undergoing psychotherapy can at times, seem like “hard work” and
requires conscious efforts toward change on the part of the client. Our job as
psychotherapists is to support you and guide you throughout this process to effect
positive changes in your life.

Relationship: Your relationship with the therapist is a professional and therapeutic

relationship. In order to preserve this relationship, it is imperative that the therapist
not have any other type of relationship with you. Personal and/or business
relationships undermine the effectiveness of the therapeutic relationship. The
therapist cares about helping you but is not in a position to be your friend or to have
a social and personal relationship with you. Gifts, bartering and trading services are
not appropriate and should be shared between you and the therapist.

Personal Information and Record-Keeping: Your personal information will be

collected, used, and stored as necessary to ensure the provision of high-quality
psychotherapy services in accordance with the requirements of relevant privacy
laws. You can request that changes be made to records if you believe them to be
inaccurate.

Confidentiality: All client information is kept strictly confidential. No information will

be communicated to a third party without your permission. When records (i.e.,
reports) are requested by a third party (e.g., school, doctor, insurance), your written
authorization is required before any information can be released.

The therapist may consult with a supervisor or colleague for the purpose of ensuring
the best possible care; however, in such cases, your name will not be shared and the
person with whom the therapist consults will also be bound by the same rules of
confidentiality. In addition, it may be beneficial to consult with other health
practitioners in your “circle of care” (e.g. your family doctor) if it is relevant to your
progress in therapy. However, the therapist would ask for your expressed consent to
do so prior to making contact or disclosing any information.

There are a few exceptional circumstances in which the therapist may have a legal or
ethical obligation to disclose your personal information without your consent, which
are listed below:

1. If there is an imminent risk of serious bodily harm to either yourself or

someone else, we will need to take action to ensure safety, which may include
contacting the police or alerting other individuals of the potential danger.
2. If you disclose information about a child or elderly individual at risk of abuse
or neglect, we will need to report it to the appropriate authorities.
3. If you inform us about another regulated health professional who has abused
you or is abusing others, we will need to report this to the appropriate
authorities.
4. If we receive a subpoena or other court order, we may have to disclose your
personal information as required by law.

Whenever possible, we will notify you if we need to take any of the actions outlined
above.
In-clinic therapy: If you are coming for therapy in the clinic, it is important to
remember that you must keep a distance of 2 meters while in the therapy room. Your
therapist will inform you about all seating arrangements in order to ensure this.

Virtual/Web-Based Sessions: We do offer psychotherapy virtually (via a secure

video-calling platform). The main benefit of this is that the limitations imposed by
geographical distance and travel times are greatly reduced or eliminated. Some of
the downsides to virtual psychotherapy include that some information is lost when
conducting therapy via video conferencing services (e.g. body language); internet
connection problems or low internet speeds may cause interruptions in the session
or result in reduced audio or video quality; and additional precautions may need to be
taken to ensure privacy and confidentiality (e.g. making sure nobody around you can
hear what you’re discussing during the session).

Contact Outside of Therapy (including Social Media Policy): As a general rule, we do

not form or maintain relationships with clients or former clients outside of the
professional relationship involved in the provision of psychotherapy services. This
includes social media, wherein we will not elicit or accept social media contact of a
personal nature. In the event of incidental contact outside of therapy (e.g. if we ran
into each other in a public place), we would leave it up to you to decide whether or
not you’d like to initiate contact in order to respect your rights to privacy and
confidentiality.

Fees and Billing: The AB clinic charges a fee of Rs. X for a 50-minute session of
individual psychotherapy. Fees are paid at the end of each session via GPay or cash.

Lateness, Missed Appointments, and Cancellation Policy: If you need to cancel an

appointment for any reason, please give us as much notice as possible. If the
therapist needs to cancel an appointment for any reason, he/she will give you as
much notice as possible.

If you cancel an appointment on the day of the appointment (i.e. the same day) or do
not show up for a scheduled appointment, it will be treated as a “missed
appointment,” and you will be charged the full fee for the session (exceptions may be
made for extenuating circumstances such as a medical emergency).
If you are late for an appointment, the session will be shortened by the time that you
are late. If the therapist is late for an appointment, he/she will make the time up to
you by adding it to the end of the current session or a later session if this is not
possible.

Termination: Either the client or the therapist may end therapy at any time. Your
voluntary involvement allows you to discontinue at any time. If your therapist feels
you are no longer benefitting from therapy or your therapist feels there is a conflict in
values, they may discuss termination. If you desire additional counselling, your
therapist will provide you with a referral competent to address your issues.

Therapist’s Incapacity or Death: In the event the therapist becomes incapacitated or

dies, it will become necessary for another therapist to take possession of client
records. By signing the Informed Consent and Privacy Practices Receipt, you give
consent to another licensed mental health professional at AB Clinic to take
possession of your files and records and provide you with copies upon request or to
deliver them to a therapist of your choice.

Scope of our services: We are qualified to work with a variety of clients and
problems, but sometimes, we may not have the training needed to address a
particular concern. If this is the case, we will discuss it with you and make sure that
you receive a referral to another professional who is better qualified to serve you. If
you are looking for a very specialized treatment for an eating disorder,
obsessive-compulsive disorder, attention-deficit/ hyperactivity disorder, panic
disorder, or substance use disorder, or a very specific treatment method such as
exposure and response prevention, and if you do not want to explore how personality
dynamics, personal history, and internal conflicts may contribute to the above
problems, we may not be the best therapist for you. Also, if you are having current
hallucinations/ delusions, severe thoughts of suicide or self-harm, or extreme Bipolar
mood swings, you may need more support than we can offer you through weekly
psychotherapy, and we reserve the right to refer you to a different or more intensive
treatment if we believe you exceed the level of care we can offer.
Contacting us: If you need to contact us, we can be reached by phone at 0000 or by
email at [email protected]. If we are not immediately available, we will do our best
to get back to you within 24 hours. We are not usually available to provide crisis
support, and in such cases, we recommend that you contact a crisis support service.
 AB Clinic: Informed Consent Agreement

By signing here, I indicate that I have read and understood the contents of this
document. I have also had the opportunity to ask any questions that I may have and
have had them answered. I consent to engage in the psychotherapy services being
offered.

_____________________ ___________________ ______________

Name of the client Signature Date

_____________________ ______________

Name of the guardian/parent (if applicable) Signature