Informed Consent for Online Psychotherapy
Please read this carefully and ask about anything that is unclear before signing. You may withdraw consent at any time.
1. Parties
Therapist name (with qualifications, e.g. M.Phil. Clinical Psychology, RCI CRR no. if applicable):
Client name:
Date:
2. Nature of therapy
Psychotherapy is a collaborative process. It can bring meaningful relief and change, and it can also involve discomfort as difficult experiences are discussed. Outcomes cannot be guaranteed. Your therapist will discuss their approach, the expected frequency of sessions, and will review progress with you periodically. Therapy is voluntary: you may pause, decline any technique, or end therapy at any time, and you are entitled to a referral to another professional if you wish.
3. Confidentiality and its limits
What you share in therapy is confidential, in line with professional ethics and the confidentiality protections recognised by the Mental Healthcare Act, 2017. Your therapist will not confirm to others that you are a client without your consent. There are specific, limited exceptions where information may be disclosed:
- A serious and imminent risk of harm to your life or safety, or to the safety of another identifiable person — disclosure limited to what is needed to keep people safe (which may include your emergency contact or emergency services).
- Information indicating abuse or neglect of a child, where reporting is legally mandated (including under the POCSO Act, 2012).
- A valid order of a court or other legal obligation to disclose.
- Clinical supervision or peer consultation, where the therapist discusses work without revealing identifying details.
- Any disclosure you specifically authorise in writing (for example, coordination with your psychiatrist).
Wherever possible, your therapist will discuss a disclosure with you before it is made.
4. Online sessions (teletherapy)
Video platform used for sessions (e.g. Google Meet — end-to-end setup discussed in session):
- Please join from a private space where you can speak freely, using headphones where possible. The therapist will do the same.
- Sessions are not recorded by either party without explicit, separate written consent.
- If the connection drops, we will try to reconnect for 10 minutes; failing that, the session continues by phone or is rescheduled.
- At the start of online work, you agree to share your physical location for each session and an emergency contact, so help can be arranged in a crisis.
- Online therapy is not suitable for emergencies. In a mental health emergency, contact Tele-MANAS 14416 (Govt. of India, 24x7), emergency services 112, or the nearest hospital.
5. Fees, payment & cancellation
Fee per session (₹):
Session duration (e.g. 50 minutes):
Payment method and timing (e.g. UPI within 24 hours of the session):
Cancellation notice required (e.g. 24 hours):
Late-cancellation / missed-session charge (e.g. 50% / 100% of session fee):
Fee revisions will be discussed with you in advance and take effect only from a mutually agreed date. An itemized invoice or receipt will be provided for payments.
6. Records and your rights
Your therapist keeps brief, professional records of appointments and clinical notes, stored securely and retained as required by law and professional guidelines. Consistent with the rights framework of the Mental Healthcare Act, 2017, you may request access to your basic medical records; access to specific parts may be limited only on the narrow grounds the law allows, and any such decision will be explained to you. You may also request correction of factual errors.
How records are stored (e.g. encrypted practice-management software; paper files in locked storage):
7. Consent
Please tick each statement you agree to (tick all that apply)
- I have read and understood this form, and had the chance to ask questions.
- I understand what therapy involves, including its benefits and possible discomforts.
- I understand confidentiality and its specific limits described above.
- I consent to receiving psychotherapy online under the arrangements in section 4.
- I agree to the fee, payment, and cancellation terms in section 5.
- I understand I may withdraw consent or end therapy at any time.
Client signature:
Date:
Therapist signature:
Date: