Respair Clinic - Individual Therapy (Adults) Consent Form

Welcome to Individual therapy for adults at Respair Clinic. This will be a personal, one-on-one session to facilitate psychological change in you which may reflect in your emotions, thoughts, and behaviours. Please go through the information provided in this form. It might take 15 minutes to read.

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 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

• 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.

Fees, Booking, Cancellation & Rescheduling

• Sessions are charged at the standard rate of ₹2500, and the premium rate of ₹3500 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. – ₹1250, ₹1750 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.
• Appointments are booked and paid in advance via https://respairclinic.com
• 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 minutes 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, except in case of emergencies such as imminent risk of harm to you or others.
• Court-ordered disclosure (rare).

Benefits, Risks & Limitations

Possible benefits: symptom relief, better coping, improved relationships, greater self-understanding.
Possible risks: temporary increase in distress, uncomfortable emotions, changes in relationships or self-view.

As therapy fosters personal growth, you may experience shifts in your identity or relationships, which can feel disorienting yet transformative. The therapeutic relationship itself may bring up strong emotions, some of which may be uncomfortable.

Despite these risks, research and client experiences show that therapy often yields significant benefits, including improved emotional well-being and resilience. It is however important to weigh these potential challenges against the value of personal growth and healing.

Outcomes depend on your active engagement, willingness to explore issues, nature of your concerns, unique personal circumstances and external factors in your life. How you work on what we discuss in sessions in your life outside sessions will influence your improvement and outcomes. Individual results vary and are not guaranteed.

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.

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 voluntarily. I understand the purpose, benefits, risks, limitations, and variability of outcomes of the services and consent to proceed.

I consent to reminders for my appointments with Respair Clinic to be sent to me via email, sms, or Whatsapp, on the number and email id used for booking the appointment.

Date:

Name of client:

Client Signature:

Email address:

Phone number:

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