Informed Consent

Please read through the following informed consent agreement. What follows is a basic understanding between client and therapist. In general, what are listed below are the responsibilities and obligations of your therapist, and also some expectations of you as the client. This document also contains important information about our professional services and business policies. Do not sign the informed consent unless you completely understand and agree to all aspects. If you have any questions, please bring this form back to your next session, so you and your therapist can go through this document in as much detail as is needed. When you sign this document, you will sign an agreement between us.

 

Psychotherapy

• Voluntary Participation:

All clients voluntarily agree to treatment and accordingly may terminate at any time without penalty. Counseling involves a large commitment of time, money, and energy, so you should be thoughtful about the therapist you select. In the first couple of sessions, you should be deciding whether your therapist is right for you. If you feel it is not a good match, then your therapist will be happy to assist you in finding a new therapist.

• 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 mood-altering chemicals. All clients are expected to be open and honest so your therapist can assist you with your goals. Counseling 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. 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, the 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.

 

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 counseling unless you waive that right, or a judge orders it.

• Medical/ Treatment 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 counselor.

• 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 counseling for pregnancies and associated conditions, sexually transmitted diseases, and information about alcohol or drug abuse.

 

Therapist

• 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 will do everything possible to assist you in achieving a greater sense of self-awareness and work toward helping you resolve problem areas.

• 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.

• Counseling Approach & Theory:

At Synapse, 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 that includes a Cognitive-Behavioral and Humanistic orientation to counseling. Your counselor 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 behavioral techniques designed to aid in change toward specified goals.

• Colleague Consultation, Supervision, 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.

 

Sessions Policy

• Sessions:

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 is typically 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 considered, and 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.​

 

Synapse Policies

• Contact:

Synapse 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 counseling 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 a 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 counselor 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 the 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 to be removed. You have the right to access and view your records, but you do not own the records, they are the property of Synapse Mental Wellbeing.

• 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. Synapse 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 Synapse reception: or call 108. For immediate assistance.

• Therapist’s Non-Availability:

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 counseling.

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Legal Terms

• Dispute Resolution

Any dispute arising out of or in connection with this Informed Consent for Therapy Agreement, or the therapeutic relationship between you and Synapse Mental Wellbeing, shall be resolved through binding arbitration in Bengaluru, India, in accordance with the rules of the Indian Council of Arbitration.

• Liability

Synapse Mental Wellbeing is not liable for any indirect, incidental, or consequential damages arising out of your use of our services or this Informed Consent for Therapy Agreement.

• Governing Law and Jurisdiction

This Informed Consent for Therapy Agreement shall be governed by and construed in accordance with the laws of India. Any legal proceedings arising out of or in connection with this Agreement shall be brought exclusively in Bengaluru, India.

• Arbitration

By signing this Informed Consent for Therapy Agreement, you agree to submit any dispute arising out of or in connection with this Agreement to binding arbitration in Bengaluru, India, as described above. You waive your right to a jury trial and to participate in any class action lawsuit.

 

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:

Your signature below signifies your understanding and agreement to pay any copays at the beginning of your session on the date it is provided. If you are utilizing health plan benefits, you are responsible for any amount your 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 canceled 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.

• Termination:

Additionally, if a client misses two appointments, your therapist has the option to terminate services and refer you to another clinic for services.

Refunds and Cancellations

• No Refunds After Service Commencement:

Once therapy services have commenced, no refunds will be provided for any portion of the services rendered.

• Cancellations and Terminations

If you need to cancel or terminate therapy services, please provide at least 24 hours' notice. Upon cancellation or termination, any unused portion of prepaid fees may be refunded, subject to the following terms and conditions:

• Processing Fees: A processing fee will be deducted from any refund to cover administrative costs.

• Refund Policy: Synapse Mental Wellbeing reserves the right to determine the amount of any refund and the process for obtaining it. Refunds will only cover services that have not yet been rendered.

Assessments and Reports

• Purpose of Assessments:

The assessments, reports, and diagnoses conducted at Synapse 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 environment.

• Non therapeutic use of Assessments / Reports:

It is crucial to understand that the information obtained, including any diagnoses made, is not to be utilized outside the confines of Synapse for any non-therapeutic purposes, such as:

• Legal proceedings: 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.

• Benefits or leave requests: If you need to submit mental health-related information to avail benefits or leave requests, please consult with your therapist to discuss the most appropriate documentation and procedures. They may recommend obtaining a separate evaluation specifically tailored for these purposes.

• Other non-therapeutic considerations: Any use of assessment information outside of therapeutic contexts should be discussed with your therapist to ensure it aligns with your best interests and legal requirements.

We encourage open communication with your healthcare provider at Synapse 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.

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.

 

Consent:

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

I understand the risks and benefits of counseling 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 counselor is not available.

I understand the Privacy Policy.

I understand the Terms of use.

I understand the Cancellation and Refund Policy.

 

Signature of Client (Date) _____________________________ (Not required if client is initiating sessions online)

 

Signature of Counselor (Date) _____________________________

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Other Policies

Informed Consent Form - (This form)

Privacy Policy

Terms of use

Cancellation and refund policy