INFORMED CONSENT FORM

Informed consent for video consultation for psychotherapy

I, Nivedita Moorthy, am a trainee counsellor pursuing my final year in M Sc. Counselling

psychology from Christ (Deemed to be) University.
Information on Psychotherapy Contract and Informed Consent form
This document contains important information about the risk, limitations and logistics of
counselling. When you sign this document, it will also represent an agreement between the
counsellor and you. You can discuss any questions with the counsellor when you sign this or
at any time in the future.
General Information provided About Psychotherapy:
Psychotherapy is a way to help people experiencing significant emotional distress that is
coming in the way of them being physically well, enjoying personal relationships or working
productively. Psychotherapy begins with the therapist understanding the background of the
person seeking help and the concerns that led them to seek help. Following this, the client and
counsellor come to an agreement about the goals of treatment, treatment procedures, and a
regular schedule for the time, place and duration of their treatment sessions.
About Tele-psychotherapy:
Tele-psychotherapy refers to the provision of psychotherapy services using
telecommunication technologies including email, text messaging, video conferencing, online
chat, messaging, or internet phone. Tele-psychotherapy would typically involve all aspects of
psychotherapy, except that it would be offered using telecommunication technologies.
Session Format
Sessions are normally around 45 - 60 minutes long. These sessions will take place on Google
meet, Zoom or any such video conferencing software.
You might be given homework or assignments to help you reflect and understand the
concerns being dealt in sessions. You are expected to complete it before the next session. If
because of any reason you are unable to do so you need not to worry or panic, the barriers or
difficulties faced can be discussed in the therapy sessions with the counsellor.
Cancellations And Missed Sessions
If you are not able to attend the session, it should be informed to the respective counsellor at
least 24 hours before the session so that the slot can be given to another client.
If you join the session late, the duration of the session will be what is remaining of the 60
mins scheduled. The session will be deemed cancelled if you are unable to join post 15 mins
and a new schedule would have to be decided on for the session.
If there are any difficulties in communication (technical) during the session, it will be
terminated and a new appointment will be scheduled.
Termination of Sessions
The sessions may be discontinued after discussion with the counsellor. You can discontinue
therapy if you feel that something about therapy is not working for you. If this should happen,
it would be appreciated to give feedback about what is not working for you. You may be
suggested alternate resources by the counsellor. You have the right to ask for a referral if that
would be in your best interests.
What I have understood about Tele-psychotherapy Services
Possible limitations to care:
• Video consultation has its own limitations as compared to in-person sessions and
some details could potentially be missed out despite the counsellor’s best efforts.
• Tele-psychotherapy services are by appointment only and that these consultations are
not suitable for help during a crisis or emergency.
• The counsellor contacted during a set appointment would evaluate your need and
context and guide you about the most suitable option for psychological intervention in
that context (tele psychotherapy/ in-person psychotherapy/ crisis intervention/
emergency services).
Responsibility for adverse events
You understand that the counsellor would use their professional discretion to provide
required recommendations about the type of professional service that may be required at any
given point of time. At the same time, you agree to not hold your counsellor responsible,
should any adverse events, such as lack of improvement, deterioration or situations of
potential risk of harm to self or others, occur during video consultation. You understand that
in such situations you may be advised to obtain treatment at the nearest available mental
health or emergency service.
Risks of Therapy
Therapy is the Greek word for change. Clients often learn things about themselves that they
don’t like. Often growth cannot occur until past issues are experienced and confronted, often
causing distressing feelings such as sadness and anxiety. The success of therapy depends
upon the quality of the efforts of both the counsellor and client, along with the reality that
clients are responsible for the lifestyle choices/changes that may result from therapy.
Confidentiality and Recording:
This video consultation is strictly confidential. The client should use a secure line/connection
for these consultations, in a relatively quiet and private space. The counsellor will not audio
or video record the session (either on mobile, using an app or online) and will not share the
proceedings of this consultation with any other individual or agency. However, with your
consent, the counsellor could use it to have their work supervised or for training of
professionals.
Apart from this, the details of the consultation would be shared only with a court of law, if
mandated. Confidentiality may also be breached if the counsellor feels the client may harm
themselves or others. Notes of the tele-psychotherapy consultation will be maintained by the
counsellor and stored in a safe location.
The client also undertakes that the proceedings of these consultations are not to be recorded,
shared or disseminated by the client or their relatives / other contacts to any third person or
through social media. However, despite safety measures taken, there are chances for breach
in security in technology. In such instances, both client and counsellor will not hold the other
responsible for the breach.
Records
All recordings, notes and discussions will be destroyed after the completion of the course.
Contacting the Counsellor
I will be available on e-mail and can be contacted for session logistics. I will respond within 2
working days.
Fees
You are not expected to make any form of payment for these online services.
Consent:
I hereby provide my informed consent for video consultations for tele-psychotherapy.
• The contents of this form have been explained to me in a language that I understand.
After reading/listening to and understanding all of the above, I am giving my consent
for Video sessions Yes /No
• I understand that my consent expressed online would suffice for me to receive tele
psychotherapy services. Yes/No
• I understand that I have the freedom to withdraw from these sessions at any time if I
wish. I understand that my therapist may also temporarily stop or discontinue these
sessions/recommend any other method or line of treatment if either of us experience
any difficulty in the process and in my best interest. Yes/No

By returning this form, I indicate consent for these sessions.

Name:
Date:

List of Helplines

Helpline Helpline Helpline site

Name/Organisation Number
KIRAN (Government of 1800-599-
India) 0019

NIMHANS 080- http://nimhans.ac.in/pssmhs

46110007 helpline/

CADABAM’S Suicide 096111 94949 https://www.cadabamshospitals.co

Helpline m/treatments/suicide-prevention/

Vandrevala 09999666555 https://www.vandrevalafoundation.

Foundation for com/
Mental Health

AASRA 09820466726 http://aasra.info/

http://www.aasra.info/helpline.html