INFORMED CONSENT FORM

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 coping strategies. You are working with a trainee counsellor who is under
supervision from a faculty at the Sampurna Institute of Advanced Studies.

Counseling involves a relationship between you and the trainee counsellor who has
the desire and willingness to help you accomplish your individual goals. Counselling
involves sharing sensitive, personal, and private information that may at times be distressing.
During the course of this counselling experience, if you experience any periods of increased
anxiety or confusion, please discuss it with your counselor.

The trainee counselor is available only during specific times and at other times in case
of any help you can contact Montfort Counselling Centre (MCC) - 080- 2528 4050/ 3320/
6666

CONFIDENTIALITY:

All counselling Services, including scheduling of or attendance at appointments,

content of your sessions, progress in counselling, and your records are confidential. No
information would be used without your prior permission.

EXCEPTIONS TO CONFIDENTIALITY:

● The counsellors work as a team. Your therapist may consult with other counsellor /
supervisors to provide the best possible care. These consultations are for professional
and training purposes however your identity would not be revealed.
● If there is evidence of clear and imminent danger or harm to self and/or others, a
therapist is legally required to report this information to the authorities responsible for
ensuring safety.
● Disclosure of information, if required by law.
 I have read and discussed the above information with my counsellor. I
understand the risks and benefits of counseling, the nature and limits of confidentiality,
and what is expected of me as a client of the Counseling Services.

_____________________

Signature of Client with date Signature of Trainee counselor

Purpose and Use of Recordings: As part of their professional training, graduate

students perform counseling under the supervision of University/faculty members and/or
field placement supervisors. To facilitate this training, counseling sessions are sometimes
recorded on an audio or video device. Students use such recordings to review their own
performance as counselors-in-training. Their counseling performance may also be reviewed
by their supervisor(s) and other trainees in a small group setting. All recordings are erased
after they are reviewed.

I have read and understand the above statements regarding confidentiality,

recording, and supervision of my sessions (or the sessions of my child). I give my
permission for the sessions to be recorded for training purposes as described above. I
further understand that I can withdraw this permission at any time.

_____________________ _______________________

Signature of Client /parent/guardian/teacher with date Signature of Trainee counselor