Therapy Informed Consent Form

Thank you for your interest in availing of our services.

Let us get 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 I can about the therapy process, so you are fully informed prior to starting your journey.

Introduction

Therapy is the process of resolving psychological problems, beliefs, and feelings of a person. It requires trust and confidence between the client and the therapist. 

The client should know his or her rights as well as the responsibilities for therapy. This informed consent should be able to explain the scope and limitation of this therapy including the rights and responsibilities of the parties to a therapy.

If you have questions, please do let us know and we will be happy to answer them.

About the Therapist

He is a licensed clinical psychologist in San Francisco, California. He specializes in Child Therapy, Trauma, Cognitive Behavioral Therapy, and Clinical Therapy. He has been practicing for more than 5 years and was invited to various events and has authored 2 books; "The Anxious Mind", that became a best-seller, and "Let me tell you a Secret".

Sessions

Sessions are scheduled by appointment, Monday through Friday from 9:00 am until 5:00 pm. In case you have a scheduled appointment and you wish to cancel, please do let us know a day before the scheduled session. Your therapist may have the right to cancel your session.

Risks and Expectations

Therapy begins when one opens about himself and his life experiences. In order to bring out one's self-awareness, sharing that experience with the therapist is necessary. The therapist then helps reflect back to the client the information and helps on addressing the concerns.

While undergoing therapy, old wounds, painful emotions, or traumatic experiences may be opened up again and may cause distress or discomfort. This is part of the working progress of one's therapy.

The Health Insurance Portability and Accountability Act (HIPAA)

HIPAA is a federal law that regulates the disclosure or distribution of patient information by health care providers to others. May it be personal information acquired by them or medical information that was created by them from the diagnosis upon a patient's consultation or transferred to them.

This information is called "Protected Health Information" (PHI) and this cannot be transferred or used by health care professionals without prior written consent from the patients. In order for a PHI to be considered as such, it must be informed that they have received or they have created through the course of the practice of business by a health care provider, health care plan, or healthcare clearinghouse; it must be information relating to medical or mental health or condition, payments, or diagnosis or provision of a health care service provider or professional whether it be related to past, present, or future event or information relating to the individual; and lastly, it must identify the patient or individual.

In case the information of a patient is going to be used for research, they must inform the Institutional Review Boards (IRB), as well as the patient who owns the information. 

You can know more about HIPAA at http://www.hhs.gov/ocr/hipaa

Confidentiality Agreement

As a therapist, any information shared with us is considered confidential information, and this information is also covered by HIPAA. We cannot disclose the information to anyone without us obtaining consent from you in written form. But please note that this confidentiality agreement between client and therapist is not absolute. Here are some limitations:

1. If your therapist has a good reason to believe that you will harm yourself or another person;
2. If your therapist has good reason to believe you are abusing a child or a vulnerable adult;
3. If you are committing sexual abuse;

Questions or Concerns

If you have any questions with regard to the therapy and its progress, or if you're getting unhappy with the therapy progress, please let us know immediately so we can address your concerns as soon as possible. Your criticisms and views are important to us. Feel free to contact us through this phone number: +1-123-230-3939.

CONSENT

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 have had the opportunity to ask questions regarding the therapy that I will take as well as other information about the therapy and all of which have been answered by the therapist and to my satisfaction.
• I understand the information about HIPAA as well as the confidentiality agreement that is set in this informed consent form.
• I understand my rights as well as my responsibilities as a client/patient to this therapy.
• Following all the understanding above, I hereby give my full consent to the foregoing treatment.

By signing this informed consent and in my capacity as a therapist:

1. I affirm that I have fully explained the information here in this informed consent to the client/patient and by which the information shared was well understood by the said client/patient;

2. I have given the client/patient the opportunity to ask questions and all which were answered to the best of my knowledge and to the satisfaction of the client/patient's understanding