Story of Lyminality
While starting your therapy, it is important to know what to expect and understand your rights and commitments. This consent form is an attempt to be as transparent with you as I can about the therapy process, so you are fully informed prior to starting your journey.
As a therapist, any information shared with me is considered confidential information. I will not disclose the information to anyone without obtaining consent from you. But please note that this confidentiality agreement between the client and therapist is not absolute. Here are some limitations:
In case of harm to self, the therapist is required to break confidentiality for your safety and inform your caregivers.
In case of harm to others, the therapist is legally required to contact the police for the protection of the intended victim.
In case of abuse or neglect of a child, adolescent, or adult, the therapist is required to inform the legal authorities.
If you are a minor
If mandated by any court of law
Your psychological records including items such as personal information, progress notes, and evaluations, will be kept confidential and will be shredded/deleted 2 years after your file has been closed.
Sessions are scheduled by appointment, Monday through Saturday from 9:00 am until 5:30 pm.
Each weekly session will be 60 minutes from the time of your appointment.
We will mutually agree on the day, timings, and mode of therapy
Cancellation and Rescheduling
In case you have a scheduled appointment and you wish to cancel or reschedule, please do let me know 24 hours before the scheduled session failing which, the session will be chargeable as per your session fee.
A session will be treated as 'client cancellation' if there is a delay of more than 20 minutes in a session.
The exceptions for any last-minute cancellations are unexpected illnesses or emergencies.
Your therapist will honor the time commitments and may have the right to cancel your session with sufficient notice.
You can reach me over email for any queries: email@example.com.
WhatsApp can be used for sharing zoom links, and for confirming/canceling/rescheduling sessions.
You can reach me on phone between 9:00 am and 5:30 pm for emergencies
An invoice will be emailed for four sessions to be paid before the 5th of every month. You can choose the mode of payment and decide if you want to pay in advance or post four sessions.
The length of your therapy and the timing of the eventual termination of your treatment depends on the specifics of your goals and the progress you achieve. We can discuss a plan for termination with you as you approach the completion of your treatment goals.
If you are not benefiting from therapy, either of us may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referrals, changing your treatment plan, or terminating your therapy.
In such an event, I will recommend that you participate in at least one, or possibly more, termination sessions intended to facilitate a positive termination experience and give us an opportunity to reflect on the work that has been done.
By filling out this informed consent form I affirm that:
I have read the information about the therapist and the therapy above and have understood them very well.
I understand my rights as well as my responsibilities as a client/patient in this therapy.
Following all the understanding above, I hereby give my full consent to the foregoing treatment.
Thanks for submitting!