Informed Consent and Intake Form

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Psychotherapy

• Voluntary Participation: All clients voluntarily agree to treatment, and accordingly may terminate if they wish to do so.
• Client Involvement: All clients are expected to show up to appointments on time, be prepared to focus on and discuss therapy goals and issues, and will not attend while under the influence of non-prescribed and/or illicit drugs, or alcohol. All clients are expected to be open and honest so your therapist can assist you with your goals. Therapy calls for a very active effort on your part. In order for therapy to be successful, you are encouraged to work on things we talk about both during our sessions and at home. Inconsistent attendance can negatively affect your therapy progress.
• Guarantees: The majority of people do get better in therapy and accordingly, your therapist makes NO guarantee of results. It is not possible to guarantee results such as: becoming happier, saving marriages, stopping drug abuse, becoming less depressed, and so forth.
• Risks of Therapy: Just as medications sometimes cause unexpected side effects, counselling can stimulate painful memories, unanticipated changes in your life, and uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. In some cases client’s symptoms become worse during the course of therapy, occasionally necessitating hospitalization. Another risk of therapy is that throughout the process of therapeutic change, it is not uncommon for clients to reach a point of change where they may feel they are different and no longer able to be the same person they were upon entering therapy. At times these feelings can be unsettling.
• Benefits of Therapy: The benefits of therapy can include: a higher level of functional coping, solutions to specific problems, new insights into self, more effective means of communicating in relationships, symptomatic relief, and improved self-esteem.

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Therapist

• Credentials and Qualifications: Counselors at Innovative Psychological Consultants hold a variety of degrees in the field of psychology such as Masters or Doctoral Degrees in Psychology, Family Therapy, and Psychiatry. You can check the therapist’s profiles and qualifications here.
• Therapist Involvement: Your therapist will be prepared at the designated time, (barring emergencies), and will be attentive and supportive in meeting the therapy goals and do everything possible to assist you in achieving a greater sense of self-awareness and work toward helping you resolve problem areas.
• Counselling Approach & Theory: At Mind and Brain, we believe that each individual is different and unique and as such do not limit ourselves to any 1 approach. Your therapist generally uses an eclectic therapy approach and may use different evidence modalities as the need arises. Your counsellor focuses largely on client responsibility in therapy, building a relationship with clients, creating a nurturing environment conducive to change, exploration of past events and how they continue to affect you today, analysis of underlying belief systems and their relation to inadequate functioning or hindrance to change, and implementation of specific emotional, cognitive, and behavioural techniques designed to aid in change toward specified goals.
• Colleague Consultation and Peer Supervision: In keeping with standards of practice, your therapist may consult with other mental health professionals regarding the care and management of cases. The purpose of this consultation is to ensure quality of care. Your therapist will maintain complete confidentiality and protect your identity by not using real names or any identifying information.

Confidentiality

• Confidentiality and Privilege: The information and content shared in therapy will remain confidential, except as noted in the next section: Exceptions to Confidentiality and Privilege. Your information will not be shared with anyone without your written consent. Your information is also privileged, which means that your therapist is free from the duty to speak in court about your counselling unless you waive that right, or a judge orders it.
• Patient Records: In compliance with the Mental Health Act of India, patient records, including assessment reports and session summaries, will be retained for the legally mandated duration. Patients may request access to their medical records at any time with a week’s notice
• Exceptions to Confidentiality and Privilege: Your therapist is legally obligated to violate confidentiality under the following circumstances:
  • When the therapist has reason to suspect that the client has been, or is currently, involved in the abuse or neglect of a child
  • When the therapist has reason to suspect that the client has been, or is currently, involved, in the abuse or neglect of vulnerable adults
  • If a client is pregnant and taking street drugs  If the client reports sexual misconduct by another counsellor.
  • If a client is a serious danger to themselves, i.e., if suicidal
  • If a client is a serious danger to someone else, i.e., if homicidal
  • If the courts order copies of records. 
  • Confidentiality has limitations for minor clients. Parents and guardians have the legal right to access a minor client’s records. Minor clients do have the right to complete confidentiality in obtaining counselling for pregnancies and associated conditions, sexually transmitted diseases, and information about alcohol or drug abuse.

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Sessions Policy

• Meetings: Once we have agreed to work together, we will usually schedule one appointment every 1-2 weeks at a time we can agree upon. Therapy sessions typically warrant intervals of at least 5-7 days between sessions and the frequency will be suggested by the therapist based on the client’s needs and availability.
• Length of Therapy:
  • The session length typically is 45 minutes. Occasionally sessions may run as long as 55-60 minutes. Because our meetings are your time, you are expected to come to each session with a sense of what it is you would like to discuss or work on during that particular session.
  • The length of therapy is quite variable based on client motivation, the number and severity of issues to resolve, and work efforts outside of therapy sessions. On average, many people feel they have obtained what they were looking for in 10-25 sessions. For some, it is fewer and for others, it may go longer.
• Cancellation, No Show or Late Arrival: In general, all clients must provide the therapist with a minimum of 24 hours notice in the event of a cancellation. Clients will be charged for appointments that are not cancelled at least 24 hours in advance and for all no-shows. A one-time emergency can be  Any emergencies will be decided on a case-by-case basis Clients arriving late will not be provided with an extension of time beyond what they were scheduled so as not to disrupt other client appointments. No reduction in fees will result from shortened sessions due to a client’s late arrival.
• 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 benefiting from therapy or your therapist feels there is a conflict in values they may discuss termination. If you desire additional counseling your therapist will provide you with a referral competent to address your issues.

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Hospital Policies

• Contact: The hospital does not provide the contact details for any individual therapists and encourages clients to contact the reception to direct any calls if needed.
• Young Children in the Waiting Area: We are not able to assume responsibility for the care of young children during therapy sessions. Having young children is generally disruptive to the counselling process, and we ask that you arrange for their care so you may come alone. If you have difficulty arranging child care elsewhere, please talk with your therapist. Children old enough to be responsible for themselves may wait in the reception area.
• Custody Issues & Therapy for Minors: It is the policy of IPC that for minor children, where legal custody is split (joint) between parents or guardians who are no longer married or cohabiting, we need authorization and signature from both parents on our Informed Consent and Confidentiality Notice prior to the child being seen. These forms can be downloaded from our website and completed prior to arrival.
• Ethical Guidelines: Your counsellor follows the American Psychological Association (APA) ethical guidelines, as well as those rules dictated in the MN Board of Psychology Practice Act. Copies of these materials can be obtained from: American Psychological Association 750 First Street NE Washington, DC 20002 1-800-374-2721.
• Medical Records: The laws and standards of our profession require that we keep treatment records. You are entitled to receive a copy of the records unless we believe that seeing them would be emotionally damaging, in which case we will send them to a mental health professional of your choosing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. We recommend you review them in your therapist’s presence so we can discuss the contents. All client records include a data sheet filled out prior to therapy, a chronological listing of appointments and fees, a copy of signed releases, copies of any correspondence regarding your case, a copy of the signed informed consent packet materials, and a copy of all therapist notes. All records will be maintained by your therapist in a secured area for a period of time as prescribed by the Mental Health Act 2020 or any such revisions, addendums, or additional acts which were recognised and published in the official channels at the start of service, from the time of service termination. As a client, you have a right to access your records. You also have a right to contest material in your records and it will be duly noted in your record. You do not have a right to alter your records or dictate information be removed. You have the right to access and view your records, but you do not own the records, they are the property of Mind and Brain Hospital.
• Counseling and Records for Minors: If you are under 18 years of age, please be aware that the law provides your parents the right to review your treatment records as well as obtain information from us about your diagnosis, progress, and treatment. It is our policy to request an agreement from parents that they agree to avoid unnecessary review of records and involvement in your treatment with us. If they agree, we will only provide them general information about our work together, unless we feel there is a high risk that you will seriously harm yourself or someone else. In this case, we will notify them of our concern.
• Professional Fees: Therapists may schedule diagnostic sessions at the start or when a need arises, which is more expensive. Follow-up therapy sessions are less expensive. Fees vary for other services provided such as testing or psychiatry. A fee schedule for services can be provided at your request.
• Health Insurance: You should be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis for benefits to pay for services. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored on a computer. Although all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they can share the information with national medical information databanks. It is important to remember that you always have the right to pay for services yourself to avoid the potential problems described above. Please keep us informed of changes in your financial status and insurance or medical assistance eligibility. You may be responsible for charges incurred if your coverage has changed or lapsed and you do not inform us in advance.
• Phone Availability: Your therapist may often not be immediately available by phone, because of other obligations. The hospital may provide you with emergency supportive sessions with any other available Therapist.
• Emergency & Interruption of Therapy: In the event of any mental health or substance abuse emergency, we encourage you to contact the hospital reception: or call 108 for immediate assistance.
• Non-availability of Therapist: When your therapists are on vacation or plan to be unavailable for a brief period of time, we will provide you with the name and number of another therapist you can contact with questions or come in to see as needed. In the event of a longer interruption of therapy, we will make appropriate referrals as needed.
• Client Satisfaction Survey: We welcome feedback about the services you receive. We are dedicated to improving the delivery of services to clients. Attached is a client satisfaction survey that you may fill out at any time during or after the completion of counselling.

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Financial Agreement and Terms

• Billing and Payments: You will be expected to pay for each session at the beginning of our meetings. In the case of health insurance, you will be expected to provide any deductible or co-payments prior to our session meetings. Keep in mind that you (not your insurance company) are responsible for the full payment of fees. Therefore, it is very important that you find out exactly what mental health services your insurance policy covers.
• Copays & Co-insurance: My signature below indicates that I understand and agree to pay for any copays at the beginning of my session on the date it is provided. If I am utilizing health plan benefits, I understand that I am responsible for any amount my insurance does not cover.
• Cancellation, No Show or Late Arrival: In general, all clients must provide the therapist with a minimum of 24 hours notice in the event of a cancellation. Clients will be charged for appointments that are not cancelled at least 24 hours in advance and for all no-shows. Clients arriving late will not be provided with an extension of time beyond what they were scheduled so as not to disrupt other client appointments. No reduction in fees will result from shortened sessions due to a client’s late arrival.
• Additionally, if a client misses two appointments, your therapist has the option to terminate services.

Assessments and Reports

• The assessments, reports, and diagnoses conducted at our psychiatric and mental health hospital are solely intended for internal therapeutic purposes. These evaluations serve as essential tools to formulate personalized treatment plans and interventions designed to support your healing process within our hospital environment.
• It is crucial to understand that the information obtained, including any diagnoses made, is not to be utilized outside the confines of our hospital. This data should not be presented in family court proceedings, civil cases, criminal investigations, or any other legal context as it holds no legal validity and must not be misconstrued.
• Should there be a requirement for information to be used in a legal capacity, we strongly advise seeking a separate forensic evaluation from a qualified professional. This additional evaluation is essential for any legal proceedings where psychiatric or mental health information is needed.
• We encourage open communication with your healthcare provider at our hospital to ensure a comprehensive understanding of the limitations and appropriate use of the assessments, reports, and diagnoses conducted during your treatment. This proactive approach will help safeguard against any potential misunderstandings or legal implications.

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Research

You may choose to participate in our Research Program.

Your personal health information will be anonymized, meaning your identity will be removed. This anonymized data will be used for research purposes only. It will help us measure the effectiveness and efficiency of our treatments and services. Additionally, anonymized data is often used in scientific research publications to share findings with the broader medical community.

You have the option to voluntarily consent to the use of your anonymized data for research purposes. You can withdraw your consent at any time, and we will ensure that your data is removed from our research database. Additionally, you can request that your data be redacted from any future publications.

Please note that once your anonymized data has been published or submitted for publication, it may not be possible to redact it. This is because published material is generally considered public information.

If you have any questions or concerns about our data privacy practices, please don’t hesitate to ask.

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Consent

I have read and discussed the above information with my counsellor.

I understand the risks and benefits of counselling and the nature and limits of confidentiality.

I have also been informed of helplines to which I can reach out in an emergency when my counsellor is not available.