Individual therapy- informed consent assent form (Adolescents)

Welcome

Hi there! Welcome to Respair Clinic. You might be here because you wanted to talk to someone about some challenges in your life, or maybe your parent, guardian, doctor, or teacher thought therapy could help. This form explains who I am, what therapy is like, and how we will work together. Please read it carefully and ask me any questions you have. Therapy is a safe place to share what is on your mind, like problems at school/ college, home, or with friends. We might talk, do activities, or set goals together, and you decide what to share- we will go at your pace. Sometimes, talking in therapy might feel heavy or tough. I will do my best to make this a space which is supportive and comfortable for you to talk. As we work together, learn more about you and how to manage the difficult areas better in your life, it can also feel rewarding. Sometimes problems go away completely, but at other times figuring out how to cope or deal with them is also a good outcome. In India, some people feel may shy or nervous about therapy, but it is totally normal, and I am here to support you without judgment. Everyone’s journey is unique, and therapy can help you grow stronger at your own speed.

About Me

Respair Clinic is a psychotherapy practice owned and operated by me- 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.

Risks and Benefits of Therapy

Therapy can mean talking about the not-so-fun and hard parts of your life, during which time you may experience feelings like anger, sadness, guilt, frustration or even loneliness. Sometimes, working through these emotions can make things feel harder before they get better, as you learn new ways to cope or fully integrate your experiences. On the flip side, therapy can also be quite helpful. It can help you get along better with others, solve problems, feel less stressed, and experience more confidence. Since everyone is unique and different, there’s no way to know exactly how it will work for you. As an adolescent, you may benefit from some support to grow and reach your full potential, and therapy can often help you and your family.

Records and Privacy

I will be documenting our sessions, for my reference. Documentation can be minimal in the form of very brief session notes (e.g., attendance, topics discussed, techniques used, treatment goals). It will be retained securely for at least 10 years after the last session or until you reach the age of 25, whichever is longer. After this, the documentation will be securely destroyed without compromising your privacy.

Confidentiality- Keeping Our Talks Private

I want you to feel safe talking to me about whatever is on your mind, even stuff that is hard to share. Sometimes, this can include things you might not want your parents or guardians to know. I will usually keep everything you say just between us, unless you give me written permission to share. However, in certain situations, I am required by law or professional guidelines to disclose the information we have discussed in therapy, even if I do not have your permission. I have listed some of them below- they mostly involve your wellbeing, safety and that of others.

I cannot maintain confidentiality in these circumstances:

1. Danger to yourself or others: Safety is priority. If you inform me of any plans to seriously harm yourself or another person, based on my evaluation of it, I will inform your parent or guardian in order to keep you and others safe from any harm.
2. Risky or dangerous behaviours: If you are involved in something that could harm you or someone else, even if your intention has not been to hurt anyone, I may need to let your parent or guardian know to make sure everyone is okay.
3. Neglect or abuse: If you tell me that someone is not taking care of you properly or hurting you (eg.- physically, sexually, or emotionally harming you), or that you have been abused before – the law says I need to report it.
4. Court proceedings: As my client I can help you in therapy, however if you are involved in a court case, I will not represent you in court. In extreme circumstances, if ordered by the judge, I will have to share the material requested which can be the entire clinical record.
5. Communication: I use email and sms or whatsapp for any appointment related matters only. Please avoid sharing sensitive or health related matters on them. I cannot guarantee confidentiality.
6. Working with others:
   1. To give you the best support, I might need to talk with others you work with, like a psychiatrist or a doctor. If I think this will help our sessions, I will ask you and your parents or guardian to give me written permission to collaborate with them, in the best interests of your treatment.
   2. What we talk in in therapy could also be helpful to others you work with such as your doctor or psychiatrist. If they want to obtain any information from me, I will need written permission from you and your parents or guardian, to share information with them.
   3. The only time I will share information with your doctor even if I do not have your permission is if you are doing something that could seriously harm you.
   4. When working with children and adolescents, it is often useful to work with your teachers, speech therapist, occupational therapists etc. If required, I might need to talk with your teachers and other therapists you might be seeing, in order to help you and your family better. I will consult with you and your parents or guardian first and obtain written permission for sharing appropriate information. We will also go over what information we are sharing and how it can help.
7. Supervision: In order to give you the best help, I also talk to a senior therapist and may consult other colleagues where relevant, about our sessions. Only relevant information will be shared for purpose of case discussion. I will not share your name or any details that can identify you, and they keep our talks private too.

Working with your parents/guardian

Our therapy talks are private so you can share what’s on your mind, but sometimes we need your parents or guardian involved to help you better. I will share general updates with them, like whether you are coming to sessions, how you are doing overall, and a summary when therapy ends, without getting into private details. If I think it is important for your parent or guardian to know something to help you, I will encourage you to share it yourself and help you figure out the best way to tell them. When talking to your parents, I might describe challenges in a general way (without detailed specifics) to help them support you better. Unless it is about serious issues like abuse, wanting to hurt yourself or others, or risky behavior (as mentioned earlier), I will keep the details of our talks private. Sometimes, you and I might also agree it is helpful to bring your parents into therapy or talk to them to learn more about your difficulties and how they can be more helpful. In India, parents and guardians of kids under 18 can legally ask to see your therapy records, though this is rare. I will work with you to keep our sessions as private as possible while also keeping your parents in the loop, so we all can support you in the best manner possible.

Online Therapy

We will meet via a secure platform like Google Meet, for 60 minutes, usually on a weekly basis. Find a quiet, private space. Please do not capture any pictures or record our therapy session. If the internet drops, I will contact you via Phone, Sms, WhatsApp or email to reconnect. That said, in case of any technology failures, phone is the most reliable back up. Please try to be on time for the sessions. If you are running late please inform me.

Between Session Communication

Therapy is not for emergencies. If you are struggling or feeling unsafe and need help, please talk to your parents/ guardian right away, and you can call Child Helpline at 1098, Emergency Response Support System at 112 or TeleMANAS -14416 or 1800 891 4416 for support. I may need to tell your parent about any serious concerns to keep you safe. For non-emergency needs, like rescheduling, please email or WhatsApp me, and I will find the earliest slot, but I cannot always reply instantly.

Our sessions are online, but if we meet in person by chance, I won’t greet you first to respect your privacy. To keep therapy focused, outside our sessions, let’s only connect for therapy things, like rescheduling, via email or WhatsApp.

Ending Therapy

Your participation in therapy is voluntary. You are under no pressure and can stop at any point. I suggest one or two final sessions to talk about ending and plan next steps, as this can be healthier than stopping suddenly.

Adolescent Therapy Client

Signing below indicates that you have read the policies described above and understand that your participation in therapy is voluntary, there are limits to confidentiality, and you can end therapy at any point. If you have any questions as we progress with therapy, you can ask me (your therapist) at any time.

 

Name of Minor

Signature of Minor

Date

Parent/Guardian Agreement to Respect Privacy

I understand that, as a parent, I can legally ask to see my child’s therapy records since they are under 18. To help my teen feel safe and open up in therapy, I agree to support their privacy by limiting requests for detailed session notes. Instead, Dr. Vaisnvy Kapur will share general updates with me, like how my teen is doing and if they are attending sessions etc, to keep me informed while respecting their trust in therapy. I understand I can always talk to Dr. Vaisnvy Kapur about any concerns or questions.

Yes

No

I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to Dr. Vaisnvy Kapur’s professional judgment and may sometimes be made in confidential consultation with her consultant/supervisor.

Yes

No

 

Name of Parent 1/ Guardian 1

Signature of Parent 1/ Guardian 1

Date

 

Name of Parent 2/ Guardian 2

Signature of Parent 2/ Guardian 2

Date