CONFIDENTIALITY CONSENT FORM

Purpose of This Form

The purpose of this form is to document an agreement between the psychologist and the client regarding online psychological counseling and therapies. It explains the nature of our services, confidentiality, and exceptions to confidentiality.

I, (Your name) hereby give my consent to receive online psychological services from the psychologist according to the following terms:

1. Purpose of Services

The goal of these sessions is to support my mental well-being, provide psychological guidance, and help me navigate my concerns. I understand that I will actively participate in identifying my needs and therapy goals.

2. Client’s Rights

I have the right to decide what information I wish to share during my sessions.

I understand that online sessions may have limitations, such as internet disruptions or confidentiality risks.

I will ensure I am in a private and secure space during the sessions. If I am dissatisfied with the services, I can discuss my concerns with my psychologist or discontinue services at any time.

3. Confidentiality & Exceptions

My psychologist will keep my information confidential and will not share it without my consent, except in the following situations:

• Supervision & Professional Guidance: My psychologist may seek supervision or professional advice while ensuring my identity remains anonymous.
• Risk of Harm: If I express thoughts of harming myself or others, my psychologist has the ethical duty to take necessary action for safety, including informing relevant authorities or emergency contacts.

4. Technical Limitations & Consent

I understand that online counseling has limitations compared to in-person therapy, including potential technical issues. I will not record, share, or distribute session content without prior consent from my psychologist.

5. Consent Agreement

By signing below, I acknowledge that I have read, understood, and agreed to the terms outlined in this consent form.