Please read this form carefully. It might take 15 minutes. You may give or withhold consent freely. When you sign this document, it represents an agreement between us.

Therapist Introduction

I am Dr. Vaisnvy Kapur, Clinical Psychologist and Psychotherapist (M.Phil. & Ph.D. in Clinical Psychology, NIMHANS, Bengaluru). I am trained to see individuals (children, adolescents, and adults), couples, families, and groups for therapy. I have over 10 years of experience and currently offer only online therapy. Therapy with me is collaborative. My work style is integrative and tailored to your unique needs and circumstances.

Consultation Phase (1–4 sessions or more)

• Exploration of your and your adolescent’s concerns, history, relationships, current life context, and risks (if any).
• You and your adolescent may choose what to share. However, sometimes it is helpful to gently push oneself a little and see whether some benefit may come from enduring discomfort, if any, and continuing to engage.

• You and your adolescent have the right to inquire about my training and experience with your specific concerns.

• Purpose: mutual assessment of fit and whether I can help.
• After the consultation, we will have a discussion about our understanding of situation at hand, whether we want to proceed with therapy, and decide how to move forward based on the results of that discussion.

Sessions

• Sessions will be on Google meet, for 60 minutes, weekly, same day/time whenever possible.
• First session: photo ID verification required (teletherapy guideline).
• No recording by either party is allowed.
• Number of sessions is not fixed; decided jointly based on progress.

• You and your adolescent may ask any questions about what is happening in therapy at any time.
• If anything in therapy feels off or bothers them or you, I encourage you both to talk to me so that we can work through it openly.
• You may be invited to some sessions (separately or together with your adolescent) when clinically helpful, with your adolescent’s knowledge and, wherever possible, their assent.

Fees, Booking, Cancellation & Rescheduling

• ₹2500 per 60-minute session (including assessment sessions). Sliding-scale slots are subject to availability.
• Sessions may extend to 90 minutes only if I judge it clinically necessary (+₹1250 for extra 30 min).

• Time management is a shared responsibility. If a session runs beyond 60 minutes for any reason, the extension fee will apply and be billed.

• Fees increase annually- 10% every April – advance notice will be given. No surprises will be involved.
• Appointments are booked and paid in advance via https://respairclinic.com
• For cancellation/rescheduling without charge: inform latest by evening before the immediately previous working day ahead of appointment date. (Quick rule of thumb: Count back two full business days from your appointment date and make sure we hear from you before the end of that earlier day.)

• Best efforts will be made to reschedule within 1–2 weeks. If a suitable slot is not available or doesn’t fit your schedule, the session is charged in full with no refund.
• Genuine emergencies will be handled with flexibility and understanding, at my professional discretion and with your well-being in mind.

• Late cancellation (<1 full working day ahead of appointment date) or no-show: full fee will be charged, no refund.
• My cancellations: reschedule or full refund (1–7 working days).
• Lateness >15 min without intimation will lead to session being cancelled and charged.
• I take planned quarterly breaks (you will be informed in advance).

• If your adolescent misses three sessions in a row and you/they don’t reply to rescheduling attempts, I will assume therapy has ended and will offer the slot to someone else.

Payment details

Please check the option that you have chosen at the time of fee payment. Your choice of fee is entirely voluntary and does not affect the quality of care you receive.

• [ ] Standard fee
• [ ] Reduced fee

If you selected reduced fee:

Terms of sliding scale

I understand that:

• I will choose a fee that reflects my current financial reality.
• No proof of income is required. This operates on dignity, trust and honesty.
• The fee I select should be an amount I can pay consistently for at least the next 6 months.
• My therapist and I will check in periodically (typically every 6–12 months or sooner if my circumstances change) to see whether the fee still fits my circumstances. If my situation improves, we may adjust upward. If it becomes harder, we can discuss further.
• Reduced-fee slots are limited. I understand this is extended in good faith.

My chosen fee per session at present: ₹______

I understand and agree to the terms of sliding scale fees at Respair Clinic.

Yes

No

Confidentiality

Your adolescent’s information is strictly confidential, with some important exceptions.

Who Is the Client?

For individual adolescent therapy, your adolescent is the primary client. This means:

• Session content belongs to them and is kept private, within ethical and legal limits commonly applied in adolescent therapy.
• You, as parent/guardian, have an important role in supporting their treatment and safety, and you may receive general updates about progress, attendance, and risk concerns, but not detailed disclosure of what your adolescent shares in sessions unless they agree or there is significant risk.

Limits of Confidentiality

Confidentiality is limited in the following situations:

• Documentation will be maintained for my reference.
• Professional consultation is an important aspect of a healthy psychotherapy practice. In clinical supervision/peer/legal consultation anonymised initials or pseudonyms are used. Identifying details are not shared.
• Situations that involve risk to self or to others:
  • If your adolescent discloses a plan to harm or kill an identifiable person, I am legally and ethically required to take steps to prevent that harm.
  • If your adolescent reveals abuse or neglect of a child or vulnerable adult, I am legally obliged to report it to the appropriate authorities.
• If your adolescent is seeing other professionals (e.g., a psychiatrist), I can liaise with them only after we discuss and you/your adolescent consent.
• Court-ordered disclosure (rare).

Benefits, Risks & Limitations

Therapy will focus on your adolescent’s emotional and behavioural difficulties, relationships (including with family and peers), and overall functioning, with the goal of improving their well-being, coping, and development.

Possible benefits: symptom relief, better coping, greater self-understanding, improved communication (including with family), reduced distress, increased clarity about choices, and improved functioning.

Possible risks: temporary increase in distress, uncomfortable emotions, changes in how your adolescent views themselves or others, tension in important relationships, and the possibility that therapy may not work out as hoped.

Therapy is a collaborative process. How your adolescent and you work on what is discussed in sessions in day-to-day life will also influence outcomes.

While this is a normal part of the process, please know that I am here to support your adolescent and you throughout the process, and encourage you both to bring up any concerns so that I am able to work with you most effectively, while ensuring therapy aligns with goals discussed.

If your adolescent feels unable to manage, you or they may request an earlier session. I will do my best to accommodate this subject to mutual availability, but I cannot guarantee immediate responses or emergency phone availability.

Therapy is not suitable when there is active addiction, violence, untreated severe mental illness, undisclosed high-risk behaviour, or active self-harm/suicidal/homicidal thoughts requiring emergency care. If your adolescent has unmanageable distress or thoughts about harming themselves or another person, you and they will reach out to family or friends and the nearest emergency services or hospital, recognising that therapy is not an emergency service.

Helplines that may prove helpful (24×7 unless stated):

• iCall: 9152987821
• Aasra: 9820466726
• TeleManas: 14416 / 1-800-891-4416
• Connecting Helpline: 9922001122 / 9922004305 (12 pm–8 pm)
• Sneha (Chennai): +91-44-24640050 (10 am–10 pm)

*These have been sourced from professional networks. I also check them on a periodic basis. If you find any helpline inaccessible, please let me know.

Voluntary & No liability participation

Therapy is voluntary. Your adolescent is never under obligation or duress.  Full responsibility for your and your adolescent’s choices and behaviour remains with you. I am not liable for them.

Litigation Limitation

• Therapy at Respair Clinic is a clinical service and not intended for legal evaluations, testimony, or reports (for example, custody evaluations, divorce mediation, or fitness‑for‑duty assessments). I do not participate in legal proceedings as it compromises the therapeutic space.
• You agree neither you nor your legal representatives, nor anyone acting on your behalf will call me to provide expert testimony, legal opinions, or as a witness or request therapy records for legal purposes.
• Information will not be shared with anyone outside the therapy (including family members), except where disclosure is required by law or necessary to prevent serious harm. In the rare event of a court order, I will release only the minimum information required by law. Wherever appropriate I will act in consultation with legal counsel.
• You may request access to therapy records. If releasing full records could cause harm to anyone, I may withhold them and will inform you. Professional records are written for clinical purposes and can be misinterpreted and/or be upsetting to untrained readers. I may instead provide a clinical summary to another mental health professional you choose.
• If you wish to see your adolescent’s records, reviewing them together in a session usually works best for discussion, context, and clarity.
• You may contest any entry, but you cannot alter or demand removal of information, any contested entry will be formally noted.
• Therapy records remain the property of Respair Clinic and will be maintained securely for at least 10 years after the last session or until your adolescent reaches the age of 25, whichever is longer. After this, the documentation will be securely destroyed without compromising privacy.
• I also do not offer legal advice, medication, or medical advice, as these are outside the scope of my practice.
• Any questions about this policy can be discussed in session or in writing.

My focus is on your adolescent’s well-being as my client, and I am here to support your adolescent and you every step of the way.

Professional Boundaries

• Gifts: No gifts will be exchanged.
• Self-disclosure: Therapy space offered by me will focus on your adolescent’s needs and concerns. I reserve the right to refrain from answering any personal questions.
• Communication outside therapy:

• If we meet accidentally in public, I will not initiate contact to protect your privacy and your adolescent’s privacy. If you approach me, please know I will keep the interaction brief and professional.
• I do not accept friend/follow requests or connect with current or former clients on any social media platform (Facebook, Instagram, LinkedIn, X, etc.) to protect confidentiality and professional boundaries.
• Please use official clinic contact methods for all communication- You may use email or text (e.g., Sms, WhatsApp) for scheduling, confirming appointments, cancellations, payments, or letting me know if you are delayed.
• Since emails and texts are not fully secure, please avoid sharing sensitive details. I do not engage in therapeutic conversations over these media.

Dual/Multiple Relationships

To protect the quality of your care and my professional ethics:

• I do not accept clients with whom I or my immediate family have a pre-existing personal, social or professional relationship (except former clients returning for follow-up).
• I do not provide multiple forms of therapy to the same person (e.g., individual + couple) or see members of the same family separately as clients for therapy.

Please select:
☐ Option 1: I confirm no such relationship exists (apart from being a past client, if applicable)
☐ Option 2: Such a relationship does exist → we will discuss and possibly refer

If at any point an unforeseen multiple relationship arises, we will discuss it openly as part of the ongoing informed consent process and take reasonable steps to resolve the situation with your best interests in mind, which may include a referral to another professional.

Provision for Revision

If and as and when, either you, your adolescent, or I feel changes are needed, we may discuss, revise, and update this agreement collaboratively.

Continuity of Care and Treatment transitions

• I will provide care to the best of my ability and within professional boundaries.
• If I believe another clinician or service would better meet your adolescent’s needs, I will discuss referral options with you and your adolescent.
• Referral may involve a pause or end to our work together.
• If I am unable to continue your adolescent’s care for any reason (including non-payment and when we are not able to negotiate a new fee rate), I will provide suitable referrals to support continuity of treatment.

Termination

You and your adolescent have the right to end the sessions with me at any point during your therapy. However, I encourage and your adolescent and you to come see me for 1 or 2 more sessions before discontinuing. These sessions would offer us the chance to better understand the need to end therapy, to think about the decision together, and work towards ending the sessions accordingly. Healthy endings may be more beneficial than stopping sessions abruptly.

I reserve the right to terminate therapy sessions under certain circumstances which may compromise my ability to provide effective services, your ability to benefit from my services, or when it is legally and/or ethically appropriate to do so. Such circumstances may include, but are not limited to –

• Three missed appointments/no-shows
• Repeated non-adherence to the treatment plan or practice policies
• Refusal of recommended higher/supplemental care
• Disrespectful, devaluing, threatening, or inappropriate behaviour toward me
• Misrepresentation or withholding of key clinical information
• Persistent non-payment of fees

In such cases, I will offer referrals for a smooth transition whenever possible.

My focus is on your adolescent’s well-being as my client, and I am here to support you both throughout the process.

Thank you.

Dr. Vaisnvy Kapur
MPhil & PhD in Clinical Psychology (NIMHANS)
Psychotherapist at Respair Clinic
Bengaluru, India
Email: info@respairclinic.com
Phone (Whatsapp): +91 7411778792

Parent/Guardian Consent to Psychotherapy

I have read the consent form, had sufficient time to consider it carefully, and understand it. I am the parent/legal guardian of the below-named adolescent and have the legal authority to consent to their treatment. I understand the limits to confidentiality described in this form and the way information may or may not be shared with me. I understand the fee per session, the booking and cancellation policies, and my responsibilities regarding payment. I understand my rights, my adolescent’s rights in therapy and the therapist’s responsibilities to them. I understand that I can ask more doubts and questions for clarity as and when they arise. I know I and/or my adolescent can end therapy at any time I wish. I understand the purpose, benefits, risks, limitations, and variability of outcomes and consent to proceed. I consent to my adolescent receiving psychotherapy with Dr. Vaisnvy Kapur. I also consent to appointment reminders via email/SMS/WhatsApp, on the number and email id used for booking the appointment.

Date:

Name of parent/guardian 1:

Parent/guardian Signature 1:

Relationship to adolescent:

Email address 1:

Phone number 1:

Name of parent/guardian 2:

Parent/guardian Signature 2:

Relationship to adolescent:

Email address 2:

Phone number 2:

Contact Us

If you have any questions, please reach out at- Email: info@respairclinic.com, or

Phone (Whatsapp): +91 7411778792. You will hear back from Dr. Vaisnvy Kapur within 3 working days. Thank you.

Please note: The informed consent form will be emailed to you after appointment is booked. 

Last updated: 16/10/2025