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 the Center is committed to providing me with the highest quality of care and maintaining the confidentiality of my personal information. 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.
I understand that as part of Center’s ongoing efforts to improve services, the Center may use certain non-identifiable data from my records for research purposes. This research aims to enhance the Center’s understanding of client needs, develop better treatment options, and contribute to the fieldβs overall knowledge.
I understand that any information used in research will be anonymized to ensure my privacy. My identity will be kept confidential and will not be disclosed in any reports, publications, or presentations that may result from this research. Only aggregated, non-identifiable data will be analyzed and shared.
I acknowledge that I have read and understood this consent statement and agree that my information may be used in this manner. My participation in research is voluntary, and I may withdraw my consent at any time without affecting the services I receive from the Center.
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.
If you have any questions or concerns regarding this consent, please feel free to contact our office. Thank you for helping us improve our services and contribute to valuable research.
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