CONSENT FOR TREATMENT AND OFFICE POLICY
This consent is to certify that you (client) give permission to the clinical staff at Pune Counseling and Therapy to provide psychotherapy treatment. This includes but not limited to all clinical and administrative staff members of Pune Counselling and Therapy. You have a right to terminate the therapeutic relationship at any time without fault. The clinical staff at Pune Counselling and Therapy work as a treatment team and consult together regarding cases and you authorize the exchange of information between clinicians in order to provide the most effective treatment.
Limits of Confidentiality
Under most circumstances, all communication between you and your therapist is confidential, unless permission is given by you to convey information to a third party outside of Pune Counselling and Therapy. However, there are certain limitations to it i.e. If we are required by law or when there are compelling reasons, such as significant risk to you or someone else.
Contacting Therapists
For life threatening emergency, you may call 100.
For other times, you may call your therapist during business hours or you may email your therapist at any time smita.r.shukla@outlook.com
Appointments
1.Session Time
Sessions are 50 minutes in length (unless scheduled for longer sessions) and begin at the scheduled appointment time.
2.Late Arrival
If you arrive late, your session will be shorter.
Cancellation policy
If you must cancel your session, please let your therapist know at least 24 business hours (Monday 8:00am – Friday 8:00 pm Saturday 10:00am – 8:00pm ) in advance. You will be responsible for the full fee of any session canceled with less than 24 business hours (Monday 8:00am – Friday 8:00 pm) notice. For treatment to be most effective, clients must not be under the influence of intoxicating substances. If your therapist feels it necessary, you may be asked to reschedule your appointment for another time; this will be considered a late cancellation. In case you seek any type of treatment outside of Pune Counselling and Therapy while you are seeing a practitioner in our center, please advise your therapist about such treatment.
Fees; Billing & Payments
All services are billed at the standard rate. Weekly psychotherapy clients pay for services at the beginning of each session. You can pay cash, check, Google Pay or Paytm.
Pune Counselling and Therapy is not in network with any insurance.
I have read, understood, and agree to the information, authorization and guarantee stated above, and I understand, and agree to the above treatment plan.
Printed Name Signature Date