InnerSight Counselling & Training Centre LLP

44/1, Krishnappa Gardens counselors@innersight.in

Phone: +91 80 41649080
C V Raman Nagar www.innersight.in
Bangalore – 560093 Mobile: +91 9611405684

Informed Consent for Counselling CONFIDENTIAL

InnerSight Counselling & Training Centre LLP (InnerSight) is an independent counselling and training
services provider based in Bangalore, India. You have contacted us for counselling and are signing this
document as an indication of your understanding of the terms described below as a voluntary participant
in the counselling process

Confidentiality: You will meet your counsellor online, over phone or at their private work spaces and that
whatever you discuss with the counsellor will be held confidential between InnerSight and you, and will
not be disclosed without your consent unless legally required or there is a threat to self or others.

Data & records: You understand that your counsellor will make notes of your personal details and
counselling sessions to aid the counsellor in working with you, and that all such records are kept
confidential at InnerSight and no information revealing your personal data will be shared to you or your
representatives or any third-party unless legally mandated. At times, the counsellor may use the
information in learning exercises without revealing personal identification. No voice or video recording is
made, unless specifically discussed. Notes are typically destroyed 6 months after closure, and any new
interaction post that will be treated as a new relationship,

Voluntary & No liability participation: Counselling is a voluntary process and you understand you are
under no duress. No discussion, exercise, suggestion etc. offered as part of the process is a directions or
injunction. You continue to be fully responsible for your choices and actions, and agree that InnerSight is
in no way liable for your choices and actions, including non-action. InnerSight is not a licensed therapy
provider in nations such as the USA, Singapore etc., and, if you are in a country where such regulations
exist, you agree you are using these services on your own cognizance and to not hold InnerSight or
representatives liable in any manner.

Fees, Appointments and Cancellations: You understand that InnerSight is arranging these counselling
services with a counsellor for a consideration fee as discussed with your counsellor. You will pay the
counsellor directly. You will make prior appointments with the counsellor for availing these services and
pay all charges in full in advance or at the end of the session. Should you need to cancel or reschedule,
you agree to call us a minimum of 12 hours before the scheduled time, failing which you will pay us the
agreed fee as cancellation charges before the time of your next appointment.

Feedback and service issues: You understand that your feedback and any service issues can be
communicated directly to your counsellor and/ or to InnerSight at counsellors@innersight.in

I (We), verify that I(We) have read and

understood the above information.

(Signature of Client(s)) (Signature of InnerSight

Counsellor) (Guardian if client is younger than 18)

Date:

Your contact number: Email:

Emergency Contact: Number:

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