Thank you for choosing Respair Clinic. Please read this form carefully. It might take 15 minutes. You may give or withhold consent freely. If you wish to work with me after reading it, then you can proceed to book an appointment on the website.

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- drawing from systemic, cognitive-behavioural, psychodynamic, humanistic-existential, and other approaches, tailored to your unique needs and circumstances.

Consultation Phase (1–4 sessions)

• 60-minute weekly sessions attended by both partners on Google Meet.
• Exploration of your concerns, history, relationships, current life context, and risks (if any).
• You may choose what to share. However, sometimes it is helpful to push yourself a little and see whether some benefit may come from enduring the discomfort and continuing to engage.

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

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

Sessions

Couple therapy examines how you communicate and interact, and how these patterns affect friendship, intimacy, and needs in the relationship. You will each be invited to look honestly at your own role, express feelings clearly, and try new ways of relating. My role is to help you clarify your values, commitment, needs, and communicate with each other. The outcome of therapy may be increased satisfaction with the partnership or increased clarity about the decision to part ways. All couples have different needs and outcomes vary. As your therapist, I look forward to working with you both.

• Sessions will be 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 may ask any questions about what is happening in therapy at any time.
• If anything in therapy feels off or bothers you, I encourage you to talk to me so that we can work through it openly.
• Both partners need to be present to begin. Uneven time or unscheduled meetings with just one partner may not support your goals. If one partner is late or misses the session, I may delay or cancel it as necessary.

Fees, Booking, Cancellation & Rescheduling

• Sessions are charged at the standard rate of ₹3000, and the premium rate of ₹4000 per 60-minutes (including assessment sessions). Sliding-scale slots are subject to availability.
• Sessions may extend to 90 minutes only if I judge it to be clinically necessary (half the fee will be charged for extra 30 min. E.g. – ₹1500, ₹2000 for standard and premium fees respectively).
• 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 10% every April – advance notice will be given. No surprises will be involved.
• Sliding-scale slots are subject to availability.
• 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 you miss three sessions in a row and don’t reply to rescheduling attempts, I’ll assume you’ve ended therapy 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
• [ ] Premium 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 information is strictly confidential except in these 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 you disclose a plan to harm or kill an identifiable person, I am legally and ethically required to take steps to prevent that harm.
  • If you reveal abuse or neglect of a child or vulnerable adult, I am legally obliged to report it to the appropriate authorities.
• If you are seeing other professionals (e.g., a psychiatrist), I can liaise with them only after we discuss and you consent.
• Court-ordered disclosure (rare).

• No secrets:
  • To protect fairness and trust, I will not be in a position to hold any secrets for either partner.
  • If there is information that an individual desires to address within a context of individual confidentiality, I will be happy to provide referrals to therapists who can provide concurrent individual therapy.
  • This is to maintain the integrity of the couple relationship, and prevent any, to the extent possible, a conflict of interest for me as your couple therapist- where an individual’s interests may not be consistent with the interests of the unit being treated.
  • If any of you choose to share such information with me, I will offer you every opportunity to disclose the relevant information and will provide guidance in this process.
  • If you refuse to disclose this information within the couple’s session, I may determine that it is necessary to discontinue the therapy relationship with you as a couple, and can refer you to a different professional, if you want.

Benefits, Risks & Limitations

You as the couple are the client here. Your relationship is the core focus. Couples therapy works best when both partners genuinely commit to addressing their challenges and strengthening their relationship, and approach it with honesty and a sincere effort to work on their relationship. If either partner is not honest, unwilling to take accountability, or unmotivated to engage, it can undermine the therapy’s effectiveness.

Possible benefits: symptom relief, better coping, greater self-understanding, improved communication, reduced distress, greater intimacy, clarity about the future of the relationship.

Possible risks: temporary increase in distress and conflict, uncomfortable emotions, changes in view of relationship or self, or realisation that separation is the healthier path. Additionally, difficulties with people important to you may also occur, family secrets may be disclosed, and despite our best efforts, therapy may not work out well. I can make no guarantees about how the therapy process will be for the two of you specifically or what the outcome will be for your relationship. How you work on what we discuss in sessions in your life outside sessions will also influence your improvement and outcomes.

While this is a normal part of the process, please know that I am here to support you throughout the process, and encourage you to bring up any concerns so that I am able to work with you most effectively, while ensuring therapy aligns with your goals. If you feel you are unable to manage, you may request for scheduling a session earlier. I will do my best to accommodate you at the earliest for a session subject to our mutual availability. However, I cannot guarantee that I will be able to reply to you immediately or be able to get on a phone call with you on short notice.

Therapy is not suitable when there is active addiction, violence, untreated mental illness, undisclosed affairs, or active self-harm/suicidal/homicidal thoughts. If you have unmanageable distress or thoughts about harming yourself or another, you will reach out to family or friends and the nearest emergency services or hospital with the knowledge that therapy is not a space for urgent and emergency access.

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. You are never under any compulsion or obligation. Full responsibility for your choices and behaviour remains with you. I am not liable for them.

Litigation Limitation

• I do not participate in legal proceedings (testimony, reports, custody evaluations, divorce mediation, etc.) as it compromises the therapeutic space.
• You agree neither you nor your legal representatives, nor anyone acting on your behalf will call me as a witness or request therapy records for legal purposes.
• In the rare event of a court order, I will release only the minimum information required by law.
• Therapy records remain the property of Respair Clinic and will be maintained securely for a period of at least 7 years.
• You may request access to your records. If releasing full records could cause harm (to you or others), I may withhold them and will inform you.
• Professional records can be misinterpreted and/or be upsetting to untrained readers. I may instead provide a clinical summary to another mental health professional you choose.
• Review is best done together in session for proper discussion and context.
• You may contest any entry (your objection will be noted), but you cannot alter or demand removal of information.
• 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 well-being as my client, and I am here to support 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 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. 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 or I feel changes are needed, we may discuss and 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 needs, I will discuss referral options with you.
• Referral may involve a pause or end to our work together.
• If I am unable to continue your 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 ensure uninterrupted support.

Termination

You have the right to end your sessions with me at any point during your therapy. However, I encourage you to come see me for 1 or 2 more sessions before you discontinue therapy. These sessions would offer both of 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.

Thank you.

Dr. Vaisnvy Kapur

Respair Clinic- Consultant Psychotherapist

MPhil & PhD in Clinical Psychology (NIMHANS)

Bengaluru, India

Email: info@respairclinic.com

Phone (Whatsapp): +91 7411778792

Client Consent to Psychotherapy

I have read the consent form, had sufficient time to consider it carefully, and understand it. I understand the limits to confidentiality. I understand the fee per session and my rights and responsibilities as a client, and my therapist’s responsibilities to me. I understand that I can ask more doubts and questions for clarity as and when they arise with my therapist. I know I can end therapy at any time I wish. I agree to participate in psychotherapy. I understand the purpose, benefits, risks, limitations, and variability of outcomes of the services and consent to proceed.

I consent to appointment reminders via email/SMS/WhatsApp, on the number and email id used for booking the appointment.

Date:

Name of client 1:

Client Signature 1:

Email address 1:

Phone number 1:

Name of client 2:

Client Signature 2:

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: 23/09/2025