TERMS OF SERVICE
INFORMED CONSENT FORM
PSYCHOLOGIST- CLIENT CONTRACT
Ms Vrinda Ahuja
RCI Registered Mental Health Professional, Rehabilitation Counselor, Career Counselor
This document informs you of our policies regarding the collection, use, disclosure of personal details, and other important information when you use the service provided by us and the choices you have associated with that data.
Information Collection and Use
While using the services, you may be required to provide us with certain personally identifiable information that can be used for the treatment. Personally, identifiable information may include but is not limited to, your name, phone number, postal address, details of experiences/incidents related to your private life, and other information (“Personal Information”). Further, by signing this document to avail of the services, you agree to and are hereby bound by these Terms of Services. Unless explicitly stated otherwise, any new methods which may be added to the services, are subject to these Terms of Use.
We may, in our sole discretion, make changes to these Terms of Use, from time to time with or without notice to you. Each time changes are made to these Terms of Use, you shall be notified of the revised version of these Terms of Use. Your continued use of the Service following such changes constitutes your acceptance of any such changes. You can review and are encouraged to check, from time to time, the most current version of these Terms of Service. At all times, the latest version of these Terms of Service shall be binding and prevail over any other version. Furthermore, we reserve the right to amend, discontinue, limit, disable, terminate, or cancel any feature of the services at any time.
Meetings
During this time both parties shall decide if your psychologist is the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun the psychologist will usually schedule one 50-minute session per week at a time as agreed upon. Although some sessions might be longer or more frequent. Once an appointment hour is scheduled you will be expected to pay for it unless you provide 24 business hour advance notice of cancellation.
Professional Fees
Our session fee is INR 1000/- (Rupees One Thousand) for each session. In addition to weekly appointments, we charge this amount for other professional services you may need, consulting with other professionals with your permission, preparation of records of the treatment summaries, and time spent providing any other services you may request from the psychologist. If you become involved in legal proceedings that require our participation you shall pay for all our professional time, including but not limited to preparation, transportation costs, and other relevant requirements.
Limits On Confidentiality
Professional ethics and law protect the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign a written authorization.
Furthermore, your signature on this Terms of Service provides consent for those activities, some of them are as follows:
• We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, we make every effort to avoid revealing the identity of the client. The other professionals are also legally bound to keep the information confidential. We will notify you about such consultations at our own discretion.
• If a client seriously threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. Subsequently, a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the client to the client or others, or there is a probability of immediate mental or emotional injury to the client.
• If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment. We cannot provide any information without your (or your legal representative’s) written authorization, or a court order.
• If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.
• If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. There are some situations in which we are legally obligated to disclose personal information, in order to make a necessary attempt to protect others from harm, and we may have to reveal some information about a client’s treatment. Some of the situations are mentioned as follows:
• If we have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that your doctor makes a report to the appropriate governmental agency.
• If we determine that there is a probability that the client will inflict imminent physical injury on another, or that the client will inflict imminent physical, mental or emotional harm upon him/herself, or others, we may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the client.
Billing And Payments
You will be expected to pay for each session at the time it is held unless we agree otherwise. If your due payment has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.
Termination
We may suspend the sessions in accordance with the developments in your treatment by giving you prior notice. Further, we may terminate the service at any time without your consent. You may terminate the sessions by giving prior notice to the psychologist.
Limitation of Liability
You acknowledge and agree that in no event will We (including, without limitation, our affiliates and their respective agents) be liable for any direct, indirect, special, punitive, incidental, or consequential damages or losses (including, without limitation, damages for loss of profits, business interruption, loss of programs or information, and the like) arising out of your use of or inability to use the service, or improper use of the Service, even if you have been advised of the possibility thereof and regardless of the form of action.
Governing law
These Terms of Use shall be governed by the laws of India, without regard to principles of conflicts of law.
Please print your name and sign below to indicate that you have understood and agree to these terms of service.
I, (PRINT FULL NAME) _________________________________________________________, understand and agree to the above terms of service, policies, fees and procedures in full and acknowledge that my agreement is a fair and reasonable condition of the provision of services for myself and/or my child.
Signed: _____________________________________________________ Date: ____ / ____ / _______
On behalf of:
_____________________________________________________________
(Print names of any children who are to receive services in BLOCK CAPITALS)