Online Counseling Consent Form

Name:___________________________Date______________Age:___________________
Gender:__________________Education:________________________________________

Wonderful You (Psycho-Solutions Clinic) aims to provide peace and satisfaction to those who
have psychological/mental health challenges.
 Wonderful You (Psycho-solutions clinic) provide counselling services.
 Counselling is a confidential process designed to help you address your concerns, come
to a greater understanding of yourself, and learn effective personal and interpersonal
skills to help you develop.
 It involves a supportive, respectful and understanding relationship between you and a
trained counsellor, who has the desire and willingness to help you accomplish your
individual goals.
 Counselling involves sharing personal information; this process may sometimes be
distressing and in the course of counselling, there may be periods of increased anxiety
or confusion.
 The outcome of counselling is often positive; however, the level of satisfaction for any
individual is not predictable.
 Please read this important information about our services and policies carefully and
please sign it.
 Important Points to Remember
Regarding Counseling Session:
1) You are here to take counselling from the best Psychologist and Counsellor of the city. So be
confident and have faith on the Psychologist/Counsellor, as you will be out from your problem
very soon.
2) High concentration is must during the counselling session. More you concentrate, faster you
get the result.
3) To get best result of the counselling, you need to practice all the prescribed techniques and
follow up at your home regularly.
4) Counselling time is limited, so be specific in your expression and also be mindful about time.
5) Please follow the counselling policies throughout the course of counselling. If your medical
condition becomes unstable or you violate the policies like (if you don’t follow suggested
exercises/techniques at home, if you don’t take sessions at regular interval, if you ask for
payment credit, if you misbehave during session, if you sit drunk during session, if you seem
unwilling to take and just attending the session under the pressure of your family), the
psychologist/counsellor may terminate the counselling service at any moment.
6) Information discussed during your counselling session and all documentation is kept private
and confidential. Counsellors don't disclose your information without your consent. Some very
important exceptions to this rule are: (i) If there is a legal responsibility for the counsellor to
release information contained in records. (ii) If we believe that you are threatening imminent
physical injury to yourself or another person.
7) Without disclosing your name and identity, Counsellors may present your case at professional
conferences or study groups in order to enhance their skills and knowledge.
8) We don't provide any psychological certificate/diagnostic documents for office/school/college
leave purpose, because for counselling and any type of psycho-therapy & Hypnotherapy, there
is no need of taking break from the work.
9) We do not record counselling sessions due to privacy concern of the client. So you are not
supposed to ask for any recording of counselling session. However, in case of a minor or in
critical condition cases, online sessions can be recorded by counsellor.
10) We maintain a separate file for each client for our internal control and such file is the sole
property of the clinic, so you are not supposed to ask to get that record file.
11) As we believe that you are a nice, gentle, humble and educated person, so we expect you to
behave very nicely.
12) Please cooperate with the staff members of the clinic for the necessary documentation
formalities and have patience, if there is a waiting time.
13) All sessions should be treated like an in-office session, so no outside distractions will be
allowed. So better turn off the cell phone and close the computer programs.
14) NO third parties will be allowed, in or near the session, at any time without the counsellor's
knowledge.
15) At the time of booking your appointment, please inform us your preferred mode of online
session, so that necessary arrangements can be done.
16) Internet programs are not 100% guaranteed to be secure and confidential. So carefully, read
the Zoom/Jio/WhatsApp application policy.
17) Link for joining the Zoom/Jio meeting will be sent to you, 5-10 minutes before the session.
18) Please be ready 10 minutes prior to your session with: (i) Earphones (ii) Good Internet
Connection (iii) Notepad & Pen
19) You can note down discussion point for best utilisation of session.
20) If you join the session after the schedule appointment time or if the counsellor is not able to
reach you at the scheduled appointment time due to inconvenience at your part, your session
fee will not be refunded.
21) Technical problems may occur. If the call is disrupted, the counsellor will call you back shortly.
22) During video session, if counsellor show you any File, PPTs, Video, Image or Audio; you are not
allowed to record or take screenshot of the same, without the consent of the counsellor.
23) You need to be well-dressed during online video session and also be mindful about the
background your choose for video session.
Regarding Fees:-
24) Counselling/therapy fees in not refundable/adjustable/transferable in any case.
25) Counselling/therapy is a non-medical treatment, so counselling/therapy fees is not covered by
any insurance policy and also counselling/therapy fees is not allowed in Income tax rebate.
26) This is our private clinic; we are not associated with any insurance company or any govt
authority for claim or reimbursement process and we accept fees via online mode and such
payment itself be considered as fees receipt and no separate fee receipt will be issued from
clinic.
27) Each time, you have to pay the full fee before the session.
28) If you take extra time from the prescribed time limit then for extra time, you have to pay extra
charges Rs 500 per 5 minutes.
29) Rescheduling of your appointment date will NOT BE POSSIBLE for any reason. If you cancel
your appointment or request us for reschedule for any reason, then your advance payment will
be forfeited & will not be adjusted in any case, because we will not give your allotted time to
anybody else and reserve the allotted 1 hour time exclusively for you.
Regarding Medicine:
30) In India psychologist/counsellors are not authorised to provide any medicine, so you are not
supposed to ask for any medical advice or medicine from your counsellor.
31) Mental health treatment is a multidisciplinary approach towards the disease. If client/patient is
having self-harming or suicidal thoughts at any point of time (pre / post /during the counselling
treatment), in this condition regular treatment of medicine is must from a Psychiatrist doctor.
Counselling, all type of psychotherapies and hypnotherapy are combining part of treatment for
Mental Health.
32) If you are on medication, please deposit a photocopy (paperback) of your prescription before
the next counselling session.

I have read all the above 32 points and I understand its provisions in my conscious awareness. I
understand that the results of counseling vary from person to person and that achieving a positive
outcome depends upon my efforts as well as those of my counselor.
So, I Hereby give my consent via Email, for all the online counseling sessions from Dr. Kashika Jain. I
have been explained the proposed plan and nature of the counseling over voice call by the clinic staff.
Hence, I have no objection in this regard.
Email Address: infowonderfulyou@gmail.com

(Client Sign) (Psychologist Sign)