Consent form (For Reading)
I, am choosing to facilitate my Psychotherapy/ Psycho-Hypnotherapy / Psycho-Past Life Regression / Psycho-spiritual ONLINE Therapy- HART, sessions via Google Meet / Zoom / Skype program with Renuka Gupta, PhD,RP,CHT,PLRT. By choosing this option, I understand that:
Google Meet / Zoom / Skype is an online communication tool allowing for face-to-face video, voice, or text-based chat dialogue. Google Meet / Zoom / Skype-to-Skype calling is encrypted using the same standards utilized by the Canada government to protect sensitive information.
If you do not have Zoom / Skype account, I will be sending you a calendar link for you to click and join the video session, no app downloads needed here, just sign into your email and access the link to join for a Live video session on the day of the scheduled appointment.
For Zoom / Skype app must be downloaded and an account setup is required.
For Skype session - Search for and add therapist's username to your contacts: drrenukagupta, add me into your contact, and drop me a ‘Hi’, with your full name.
Appointments will be made via email. Intake form on page 2 , 3, 4 of this document has to be filled and sent via email atleast 12 hours before your first session. Couples need to individually fill the intake form
Please be online at least five minutes prior to session, alone, in quiet room, door closed, in a comfortable seating. Therapist will call you at the scheduled appointment time. If you are late, please inform the therapist, a therapist waits for a client for 10 min extra time, and if there is a no show, the appointment is considered cancelled and a new date is provided if asked.
FOR CANADIAN CLIENTS - For insurance covering a psychologist or Social worker via my affiliation to Licensed Professionals, your full name on credit card, card number and expiry month and year is required, which would be collected during the online session. The clinic charges the card and sends the receipt via email. Amex or Debit cards are not eligible for payment. You can also e-transfer and pay the fees before your session begins on the scheduled date. Fees for first and follow up sessions is – 175 CAD (Sliding scale is given as per the need) Sometimes receipts end up in Spam and Junk folders, so check them too. OR it can be paid by E-transfer.
For insurance covering a Psychotherapist, fees need to be paid atleast one hour prior to every session. Fees can be paid by by credit card, Interac / e-transfer (email@example.com, name Renuka Gupta) or by Paypal (firstname.lastname@example.org) for international clients. Fees for first and follow up sessions is – 145 CAD (for insured) or 30 min for 50 CAD, or 55 min for 100 CAD (for uninsured), International Clients – 100 USD, Clients from South Asia – 49 USD
For best Google Meet / Zoom / Skype picture and audio quality, a hardwired connection (via LAN cable) rather than a wireless one should be used if possible. Headphones add additional security, use a wired earphone with inbuilt mic, use fully charged Bluetooth earphones/headphones. If there are other laptops and cell phones on the same WIFI you are using, it slows down the connection, and creates interruptions, so ensure all other devices should be off WIFI , except the device you are using for the session. Also sit as near to the internet modem for better network (not be in a basement/ 2nd Floor, while the modem is on the ground floor). Please see to it when you use a Laptop, Tab or Mobile for Hypnotherapy Sessions the screensaver and Power mode settings should be checked & set at no sleep mode at 1.5 hours or more, so that the Google Meet / Zoom / Skype connection does not break due to such settings of putting your laptop or mobile on standby or sleep or screen saver mode. If your gadget goes to sleep mode due to the settings kept by you, the session gets interrupted and sometimes goes offline/ off video.
I also understand the following limitations of Google Meet / Zoom / Skype video therapy sessions:
Any internet based communication is not 100% guaranteed to be secure/confidential. I agree that Renuka Gupta should not be held responsible if any outside party gains access to Google Meet / Zoom / Skype personal or confidential information by bypassing their security measures.
In a crisis or emergency situation that needs immediate attention, whereby I am considering seriously harming myself or someone else, I will call a hospital emergency department of the country I live in.
Confidentiality should be treated like an in office session: no outside distractions, turn off cell phones, close other programs on computer and don’t be late.
Technical problems could occur. If the call is disrupted, the therapist will call back within 1 min, if the network issues persist, be ready to have a direct phone call (if in North America), to complete your session or the session will be rescheduled. Services provided by this clinic are all ONLINE.
Additional Reading For North Americans
Privacy Statement &CONSENT in Details
I am committed to protecting and respecting your privacy which means that I collect, use and disclose your personal information responsibly and only to the extent necessary for the services I provide. This document describes my policies and procedures as they relate to collecting, using and disclosing your personal information. It also offers information about how you can access your records and request correction of recorded personal information.
Who I am
Renuka Gupta, 17+ years of experience, I have obtained a degree in PhD Clinical Psychology, I am a Registered Psychotherapist in Ontario (RP, CRPO), Registered Clinical Hypnotherapist (NGH) a Certified Past Life Regression Therapist. I also have my Certification inCriminology Profiling and Forensic Science and a Diploma in Weight Management, Diet and Nutrition. Reiki Master and a Diploma in Homeopathy. You can learn more about me on my website subsection Page.
Collection of Your Personal Health Information
The purposes of collecting your personal and health information are to provide you with appropriate and quality services, contact you for service-related reasons, and prevent harm (such as reaching an emergency contact).
I will collect personal health information directly from you, except when you have provided consent for me to collect such information from others (such as a spouse, family physician, or mental health professional with whom you have previously worked), or when the law requires me to collect information without your consent (such as emergency situations where the purpose of collecting information is to prevent potential harm).
By law and in accordance with professional standards, I am required to keep a record of my contacts with and services to you. Your record includes information that you have provided to me or have authorized me to receive, such as consent forms, session notes, billing information, contact records, and correspondence that I have sent to or received relating to your service. The physical records are the property of my practice; however, you have rights regarding access to and disclosure from your record. If you contact me through my website/emails I only retain the personal information you provide and only use that information for the purpose for which you gave it to me (e.g., to respond to your email message).
College of Registered Psychotherapist of Ontario, CRPO requires that client records be kept for at least 10 years past the date of last contact for adults, and 10 years past the date at which the client would turn 18 years old. Paper records are destroyed through cross-cut shredding. Electronic information is deleted.
Use of Your Personal Health Information
Your personal health information is primarily used to provide you with psychotherapy services. The delivery of my services includes such tasks as service planning, maintenance of records, monitoring. Other uses of your personal health information include to guide and improve the quality of services provided in my practice. In addition, all individuals involved in such an activity are professionals required by law to maintain the confidentiality of all information that is accessed.
I will not be a part of discussions with any third party as per the request of the client, like insurance companies, lawyers etc. unless required by the law.
Confidentiality: State law and professional ethics require therapists to maintain confidentiality except for the following situations:
1. If there is suspected child abuse, elder abuse, or dependent adult abuse.
2. A situation in which serious threat to a reasonably well-identified victim is communicated to the therapist.
3. When threat to injure or kill oneself is communicated to the therapist.
4. If you are required to sign a release of confidential information by your medical insurance.
5. If you are required to sign a release for psychotherapy records, if you are involved in litigation or other matters with private or public agencies. Think carefully and consult with an attorney before you sign away your rights.I would not be a part of any legal proceeding unless the law requires me to.
6. Clients being seen in couple, family, and group work are obligated legally to respect the confidentiality of others. The therapist will exercise discretion (but cannot promise absolute confidentiality) when disclosing private information to other participants in your treatment process. Secrets cannot be kept by the therapist from others involved in your treatment.
7. I may at times speak with professional colleagues about our work without asking permission, but your identity will be disguised.
8. Clients under 18 do not have full confidentiality from their parents.
9. It is also important to be aware of other potential limits to confidentiality that include the following:
a) All records as well as notes on sessions and phone calls can be subject to court subpoena under certain extreme circumstances. Most records are stored in locked files but some are stored in secured electronic devices.
b) Cell phones, portable phones, faxes, and e-mails are used on some occasions.
c) All electronic communication compromises your confidentiality.
Fees: The fee for service generally covers a 55 -minute session and will be agreed upon in the first treatment session. Fees are acceptable by Credit/Debitfor every session, and a receipt would be provided for it.
Please pay your session fees prior to seeing your therapist, atleast an hour before. Payment is expected at every session; unpaid sessions will require to be rescheduled. There are no changes applicable to receipts once paid; Please ensure all details are correct upon reception of the receipt.
Fees may change, when cost of living increases may occur on an annual basis. Any extra documentation required by the client like Session notes etc will be for a certain fee.
Availability: The therapist is available for regularly scheduled appointment times. Dates of vacations and other exceptions will be given out in advance if possible.
Termination of Treatment: The therapist may terminate treatment, if some problem emerges that is not within the scope of competence of the therapist or keeping in mind the best interest of the client. The usual minimal termination for an ongoing treatment process is three to six sessions but a satisfying termination to long-term work may take longer.
Agreement for Sessions:
I have read this detailed informed consent completely and have raised any questions I might have about it with my therapist via email consultation. I have received full and satisfactory response and agree to the provisions freely and without reservations. I understand that my therapist is responsible for maintaining all professional standards set forth in the ethical principles of his/her professional association as well as the laws of the state of Ontario governing the practice of psychotherapy and that he/she is liable for infractions of those standards.
I understand that my therapist from time to time makes teaching (writing or Speech) and research contributions using disguised client material. By consenting to treatment I am giving consent to this process of professional contribution and the right to use disguised material without financial remuneration.
I agree to address any grievances I may have directly with my therapist immediately. If we cannot settle the matter between us, then a jointly agreed-upon outside consultation will be sought.
Do You Have Questions or Concerns?
These privacy policies and procedures have been developed in accordance with the laws of professional regulatory bodies and holds the ethical standards.
If you are in Canada :
Further details regarding the applicable laws, regulations and ethical standards may be found at the websites of the Ontario Ministry of Health and Long Term Care (www.health.gov.on.ca), The College of Registered Psychotherapist of Ontario (www.crpo.ca).
I, Renuka will speak with you directly to answer any questions you may have regarding this Privacy Statement and to provide you with any further information about privacy practices or limits of confidentiality that are specific to your situation. If you have a concern about my privacy policies and procedures or have a complaint about how your privacy has been handled, please do not hesitate to speak or write to me at email@example.com or firstname.lastname@example.org
I hereby acknowledge having read the above detailed consent form, and also filled and signed, the summarized version ofintake and consent form and emailed before my first session begins with the therapist.
Please go back to continue finishing the Intake Form