CONFIDENTIALITY AGREEMENT

Ambika Bhardwaj
Phone: +91 9646641994
Email : ambikabhardwaj19@gmail.com

Dear Client,
Please read the following carefully, and sign or initial as indicated. Note that I, as a
psychotherapist, am ethically bound by the terms of this agreement. As confidentiality is critical
to the psychic safety and integrity of this professional relationship, this document, when filled
out and signed by you, makes clear the limitations and permissions around the revealing of any
information shared between us. You may, by request, change the terms of this agreement at any
time, and I will provide you with a new form to complete. Granting or withholding any
permissions contained in the document will in no way affect the quality, quantity or content of
our relationship.
Please print this document, fill it out completely, scan and return the digital copy to me. Keep
original for your records.

I, __________________________________, (Client), by signing this

Agreement, hereby grant the permissions and limitations as indicated on this
document.

1. The psychotherapist (Ambika Bhardwaj) will hold confidential the

content of our sessions, my identity, and all personal information, with
the limitation of mandated reporting. Such reporting to appropriate
authorities is limited to:
 Illegal and criminal activity, pursuant to valid court order or
subpoena.
 Imminent or likely risk of danger to self and/or to others.

I agree to limiting confidentiality in my sessions to the above condition

as mandated in the Mental Health Care Act 2017 :

____________________________ _____________
Name (DD/MM/YYYY)

2. I agree to allow the psychotherapist (Ambika Bhardwaj) reveal to

others that I am or have been a client with her.

_____ yes _____ no _______ Initials

3. Should I provide written or verbal testimony to my session experience

with Ambika Bhardwaj, I hereby give permission, by initialing beside
one selected option, for the following to appear with my testimonial:
a. My first and last names, and my professional credentials ______
b. My first and last names only ________

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 CONFIDENTIALITY AGREEMENT

c. My first name only ________

d. My initials only ________
e. No reference to my identity (anonymous only) ________

I agree fully to the above, and I may choose at any time to change the terms of this agreement by
modifying this or creating a new one, and providing a copy to the psychotherapist. The new
agreement will go into effect when received by the psychotherapist.

_____________________________ _____________________
Signature Date DD/MM/YYYY

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