Confidentiality Form (for Online Session Only)

1. I understand that video/audio consultation has its own limitations as compared to in-person sessions and some details could potentially be missed out despite the psychotherapist's best efforts.
2. I understand that tele-psychotherapy services are by appointment only and that these consultations are not suitable for help during a crisis or emergency.
3. I understand that the psychotherapist contacted during a set appointment would evaluate my need and context and guide me about the most suitable option for psychological intervention in that context (tele psychotherapy/ in-person psychotherapy/ crisis intervention/ emergency services).
4. I understand that the psychotherapist 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, I agree to not hold my psychotherapist 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/ audio consultation.
5. I understand that in such situations I may be advised to obtain treatment at the nearest available mental health or emergency service.
6. I understand that this audio/ video consultation is strictly confidential. I agree to use a secure line/connection for these consultations, in a relatively quiet and private space.
7. I understand that my psychotherapist 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 my consent, my psychotherapist 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.
8. I understand that these consultations will be charged at the same rate as in-person sessions. The timing and mode of payment will be discussed with me. I understand that my consent expressed online would suffice for me to receive tele psychotherapy services.
9. I understand that my psychotherapist will discuss the tele and audio options that are available and suitable and that we will decide on what to use, considering my preference as well as the suitability of an option as assessed by my psychotherapist.
10. I understand that if there are any difficulties in communication (technical) during the session, it will be terminated and a new appointment will be scheduled.
11. I understand that I have the freedom to withdraw from these sessions at any time if I wish.
12. I understand that my therapist may also temporarily stop or discontinue these audio/video sessions/recommend any other method or line of treatment if either of us experience any difficulty in the process and in my best interest.