INFORMED CONSENT FOR PSYCHOTHERAPY AND OTHER PSYCHOLOGICAL SERVICES
I, by agreeing to the terms and conditions at the time of booking, hereby voluntarily agree to receive assessments/ therapy/ counseling for psychological/ adjustment problems at the Center for Mental Health, Pune.
I understand and agree that I will participate in my treatment plan and that I have the right to know the nature of the therapy conducted.
I understand that all the interactions during the sessions are confidential and that details of treatment and interaction won’t be revealed without my permission. However, this confidentiality will be breached in case my treating professional at the Center has cause to believe that I may be harmful to myself or to others. In such situations, I understand that the treating professional will reach out to those responsible for my welfare to ensure safety and security.
My rights will be respected while also acknowledging my worth by taking judicious precautions and engaging in positive, ethical, professional interactions, avoiding the influence of any personal biases.
I understand that advance online payment is mandatory prior to every consultation and cancellations made only prior to 48 hours will be refunded. Any cancellations made thereafter will not be refunded. Also, no refunds will be made on missing an appointment. The individual consultation charges are per person. I understand that there may be changes in the charges and fees structure of my therapist and there may be a nominal increase adjusted for inflation every financial year.
In case I have opted for online/telephonic sessions, I understand that the Center or my treating professional cannot be and will not be held accountable for interruptions caused due to issues with connectivity on either end. It is my responsibility to ensure I have privacy during my virtual sessions and no one other than the member involved in individual therapy will be a party to the session. I also understand I cannot record the session without awareness or consent of the therapist, and if found doing so, the treating professional reserves the right to cease the session, or refuse further treatment under such violations.
In case of a policy violation, misdemeanor by the client towards staff of the Center and or other people present there, the Center has the right to terminate the therapy consultations under the aforementioned situation.
Center for Mental Health,
102, Rajey apartment,
Deepa housing society,
Baner Pashan link road, Pune 21
contact@centerformentalhealth.in | www.centerformentalhealth.in | +91 93709 17252