The Safe Room Informed Consent Form
Thank you for choosing to start your journey in therapy with The Safe Room!
To foster a therapeutic relationship, both therapists and clients, hold certain rights and responsibilities, which will be informed to you through this document.
It also contains important information about professional services and business policies.
Signing this form means you consent to starting therapy with The Safe Room; however you can terminate at any point.
If you have any questions, please reach out and clear them before scheduling the session, so you and your therapist can go through this document in as much detail as is needed.
The therapist cares about helping you but is not in a position to be your friend or to have a social and personal relationship with you. Gifts, bartering and trading services are not appropriate and should be shared between you and the therapist. It is important for you to discuss any questions you may have regarding the treatment recommended by the therapist and to have input in setting goals of your therapy.
When you sign this document, it will represent an agreement between us and is BINDING on both.
● Just as medications sometimes cause unexpected side effects, counseling can stimulate painful memories, unanticipated changes in your life, and uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness.
● While psychotherapy may provide significant benefits based on empirical evidence, it may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings, or may lead to the recollection of troubling memories.
● You also understand that choosing not to engage in therapeutic treatment may also result in greater discomfort or escalating risks.
● It has been explained to you that your feedback and communication about the therapy process and impact is crucial in reducing your risk for harm, and your therapist has encouraged you to communicate any concerns or discomforts with them as soon as is feasible in your treatment.
● Another risk of therapy is that throughout the process of therapeutic change it is not uncommon for clients to reach a point of change where they may feel they are different and no longer able to be the same person they were upon entering therapy. At times these feelings can be unsettling.
Guarantees: Although the majority of people do get better in therapy, some do get worse. Accordingly, your therapist makes no guarantee of results. It is not possible to guarantee results such as: becoming happier, saving marriages, stopping drug abuse, becoming less depressed, and so forth.
Confidentiality policy• All the information shared with your therapist will kept between both of you and will not be shared with anyone else without your consent.
• If you see your therapist in a public setting, they will not acknowledge you.
Your therapist is legally obligated to violate confidentiality which may include but are not limited to the following situations:
• When the therapist has reason to suspect that the client has been, or is currently, involved in the abuse or neglect of a child or a vulnerable adult.
• For minor clients – Parents and guardians have legal right to access a minor client’s records
• If the courts order copies of records, for example, in suits of negligence brought by the client against the therapist or suits in which the mental health of a party is an in issue;
• If a client is a serious danger to themselves or someone else, i.e., if suicidal or homicidal
Meeting and Duration of therapy sessions-
- Each therapy session is for a duration of 45-60 minutes, dependent on the therapist chosen which will be shared before booking the session. However, longer sessions (90-100 minutes) can also be booked in prior notice with the availability of the therapist.
- Going beyond the allotted for the session will be charged as per the session fee rate.
- The duration of the sessions can be decided in consensus with the therapist’s availability. It varies from weekly, bi-weekly, fortnightly or monthly.
- There is no fixed frequency of sessions and you can choose to alter it with the gradual course of sessions with the therapist.
Payment and cancellation policies –
- A screenshot of the session needs to be sent prior to the session, which will confirm your scheduled appointment.
- There are no free trial sessions provided by the therapist.
- There are no refunds provided if therapy doesn’t work for you.
- Last minute cancellations (Before 24hours of the assigned time slot) will be charged the full session fee.
- The therapist will wait up to 25 minutes of the session before cancelling. In events when the client is late, the remainder of the time will be used for the session. In events when the therapist is late, the additional time will be added to the session, or the next session.
Rights and responsibilities
● You have a right to be treated with respect, dignity, and without discrimination regardless of age, gender, mental and physical status, sexual orientation, race, belief system or ethnic background.
● You can expect your therapist to make their best effort to conduct therapy as competently as possible.
● You have a right to ask questions at any time, be informed by your therapist as to their qualifications, areas of specializations and limitations, and the code of ethics which they follow.
● You have a right to be advised as to the limits of therapeutic service, discuss your treatment with others (including getting a second opinion).
● You are responsible for setting therapeutic goals for your treatment and review them as required. You should endeavor to cooperate with your therapist in evaluating the treatment process and work toward achieving your self-identified goals.
Emergencies
While we do our best to respond to any urgent matters outside of our regular appointment time, we may not be available to immediately respond to emergency situations that you experience between sessions. If you are having a mental health crisis or emergency, please contact your physician, a helpline, or go to the nearest emergency room and ask for the Mental Health Professional on call.
Termination:
Either the client or the therapist may end therapy at any time. Your voluntary involvement allows you to discontinue at any time. If your therapist feels you are no longer benefiting from therapy or feels there is a conflict in values they may discuss termination. If you desire additional counseling your therapist will provide you with a referral competent to address your issues.
By signing the informed Consent, you acknowledge that you have both read and understood all the terms and information contained herein and ample opportunity has been offered for you to ask questions and seek clarification of anything that remains unclear.