Informed Consent for Psychiatric Consultations

Please read through the following informed consent agreement carefully. This document outlines the responsibilities and obligations of your psychiatrist, and expectations of you as the client during a psychiatric consultation at Synapse Mental Wellbeing. It also contains important information about our professional services and business policies.

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Please do not sign this informed consent unless you completely understand and agree to all aspects. If you have any questions, please bring this form back to your next session, so you and your psychiatrist can go through it in as much detail as is needed. When you sign this document, you are entering into an agreement with us.

Reservation of Rights to Update Policy:

We reserve the right to modify or update this Informed Consent Form at any time without prior notice. Any changes will be effective immediately upon posting the revised form on our website. Your continued engagement with our services after the posting of any changes constitutes your acceptance of such changes. We encourage you to review this form periodically for any updates.

 

Psychiatric Consultation

Voluntary Participation:

All clients voluntarily agree to psychiatric consultation, and accordingly may terminate at any time and be refunded as per our refund policy. Psychiatric consultation involves a significant commitment of time, money, and energy, so you should be thoughtful about the mental health professional you select. In the first couple of sessions, you should be deciding whether your psychiatrist is the right fit for you. If a good match is not felt, your psychiatrist will be happy to assist in finding alternative support.

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Client Involvement:

All clients are expected to show up to appointments on time, be prepared to focus on and discuss their symptoms, history, and treatment goals, and will not attend while under the influence of non-prescription drugs or alcohol. All clients are expected to be open and honest so their psychiatrist can accurately assess needs and assist with goals. Psychiatric consultation calls for active participation. Inconsistent attendance can negatively affect progress and the effectiveness of medication management. The psychiatrist will recommend a frequency for sessions according to individual needs, and these recommendations may change during the course of consultation. If emergency sessions are required, they may be booked in accordance with the psychiatrist’s availability, subject to our emergency protocols.

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Guarantees:

The majority of people do experience improvement with appropriate psychiatric care. However, no guarantee of specific results is made, such as complete remission of symptoms or resolution of all issues. It is not possible to guarantee outcomes like becoming happier, reducing specific symptoms, or any other specific changes.

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Risks of Psychiatric Consultation:

Just as any medical treatment, psychiatric consultation and potential medication can carry risks. Consultation can sometimes stimulate painful memories, unanticipated changes in life, or uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When medication is prescribed, there are potential side effects, which the psychiatrist will discuss. In some cases, symptoms may initially worsen during the course of treatment, occasionally necessitating hospitalization. Another risk is that throughout the process of change, clients may reach a point where they feel different and perhaps unsettled by these changes.

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Benefits of Psychiatric Consultation:

The benefits of psychiatric consultation can include: a clear diagnosis (if applicable), effective management of symptoms through medication, improved daily functioning, a higher level of functional coping, and development of a comprehensive treatment plan tailored to individual needs. This can lead to symptomatic relief and an improved sense of well-being.

Confidentiality

Confidentiality and Privilege:

The information and content shared during psychiatric consultation will remain confidential, except as noted in the next section: Exceptions to Confidentiality and Privilege. Information will not be shared with anyone without written consent. Information is also privileged, meaning that the psychiatrist is free from the duty to speak in court about the consultation unless that right is waived, or a judge orders it.

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Medical/Treatment Records:

In compliance with the Mental Health Care Act of India, patient records, including assessment reports, consultation notes, and treatment summaries, will be retained for the legally mandated duration. Patients may request access to their medical records at any time with a week’s notice.

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Exceptions to Confidentiality and Privilege:

The psychiatrist is legally obligated to violate confidentiality under the following circumstances:

• When the psychiatrist has reason to suspect that the client has been, or is currently, involved in the abuse or neglect of a child.

• When the psychiatrist has reason to suspect that the client has been, or is currently, involved in the abuse or neglect of vulnerable adults.

• If a client is pregnant and taking street drugs.

• If the client reports misconduct by another mental health professional.

• If a client is a serious danger to themselves, i.e., if suicidal.

• If a client is a serious danger to someone else, i.e., if homicidal.

• If the courts order copies of records.

• Confidentiality has limitations for minor clients. Parents and guardians have the legal right to access a minor client’s records.

• Minor clients do have the right to complete confidentiality in obtaining counseling for pregnancies and associated conditions, sexually transmitted diseases, and information about alcohol or drug abuse.

 

Psychiatrist

Psychiatrist Involvement:

The psychiatrist will be prepared at the designated time (barring emergencies) and will be attentive and supportive in assessing needs and providing appropriate psychiatric care, including medication management and referrals, to assist in achieving greater stability and well-being.

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Counseling Approach & Theory:

At Synapse, each individual is considered different and unique. The psychiatrist will focus on a comprehensive assessment to understand biological, psychological, and social factors contributing to mental health. They will primarily utilize a medical approach for diagnosis and treatment planning, often incorporating medication management. They may also collaborate with therapists who use eclectic therapy approaches, including Cognitive Behavioral and Humanistic orientations, and other evidence-based practices as needed, to provide holistic care.

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Colleague Consultation and Supervision:

In keeping with standards of practice, the psychiatrist may consult with other mental health professionals (including other psychiatrists or therapists) regarding the care and management of cases. The purpose of this consultation is to ensure the highest quality of care. The psychiatrist will maintain complete confidentiality and protect identity by not using real names or any identifying information.

 

Sessions Policy

Meetings:

Upon mutual agreement to commence services, appointments will typically be scheduled at a mutually convenient time. The psychiatrist will suggest the frequency of consultations based on individual needs, the type of treatment, and availability.

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Length of Sessions:

Session length is typically minutes. A buffer time of 10 minutes is provided as sessions may occasionally run slightly longer to ensure thorough discussion. Clients may request extensions of sessions; acceptance is at the sole discretion of the psychiatrist and will be charged accordingly.

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Cancellation, No Show or Late Arrival:

In general, all clients must provide the psychiatrist with a minimum of 24 hours' notice in the event of a cancellation. Clients will be charged for appointments that are not cancelled at least 24 hours in advance and for all no-shows. A one-time emergency can be considered; any emergencies will be decided on a case-by-case basis. Clients arriving late will not be provided with an extension of time beyond what was scheduled so as not to disrupt other client appointments. No reduction in fees will result from shortened sessions due to a client’s late arrival.

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Termination:

Either the client or the psychiatrist may end the psychiatric consultation at any time. Voluntary involvement allows discontinuation at any time. If the psychiatrist feels a client is no longer benefiting from treatment or if there is a significant conflict, termination may be discussed. If additional psychiatric care or counseling is desired, a referral to a competent professional will be provided. Additionally, if a client misses two appointments, the psychiatrist has the option to terminate services and refer to another clinic for services.

 

Refunds and Cancellations

No Refunds After Service Commencement:

Once psychiatric consultation services have commenced, no refunds will be provided for any portion of the services rendered.

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Cancellations and Terminations:

If psychiatric services need to be cancelled or terminated, please provide at least 24 hours' notice. Upon cancellation or termination, any unused portion of prepaid fees may be refunded, subject to the following terms and conditions:

• Processing Fees: A processing fee will be deducted from any refund to cover administrative costs.

• Refund Policy: Synapse Mental Wellbeing reserves the right to determine the amount of any refund and the process for obtaining it. Refunds will only cover services that have not yet been rendered.

 

Synapse Policies

Contact:

Synapse does not provide the direct contact details for individual psychiatrists and encourages clients to contact the reception to direct any calls if needed.

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Young Children in the Waiting Area:

Responsibility for the care of young children during sessions cannot be assumed. Having young children present is generally disruptive to the consultation process, and arrangements for their care are requested so clients may come alone. If difficulty arranging childcare elsewhere is encountered, please talk with our reception. Children old enough to be responsible for themselves may wait in the reception area.

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Custody Issues & Consultation for Minors:

It is the policy of Synapse Mental Wellbeing that for minor children, where legal custody is split (joint) between parents or guardians who are no longer married or cohabiting, authorization and signature from both parents on our Informed Consent and Confidentiality Notice are needed prior to the child being seen. These forms can be downloaded from our website and completed prior to arrival.

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Ethical Guidelines:

The psychiatrist follows the ethical guidelines prescribed by the Medical Council of India and other relevant professional bodies.

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Medical Records:

The laws and standards of our profession require that treatment records be kept. Clients are entitled to receive a copy of the records unless it is believed that seeing them would be emotionally damaging, in which case they will be sent to a mental health professional of client's choosing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. Reviewing them in the psychiatrist’s presence so contents can be discussed is recommended. All client records include a data sheet filled out prior to consultation, a chronological listing of appointments and fees, a copy of signed releases, copies of any correspondence regarding the case, a copy of the signed informed consent packet materials, and a copy of all psychiatrist notes. All records will be maintained by the psychiatrist in a secured area for a period of time as prescribed by the Mental Health Care Act 2017 (or any such revisions, addendums, or additional acts which were recognized and published in the official channels at the start of service) from the time of service termination. As a client, there is a right to access records. There is also a right to contest material in records, and it will be duly noted. There is no right to alter records or dictate information to be removed. There is a right to access and view records, but ownership of the records is not granted; they are the property of Synapse Mental Wellbeing.

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Consultation and Records for Minors:

It is the policy of Synapse Mental Wellbeing that for minor children, where legal custody is split (joint) between parents or guardians who are no longer married or cohabiting, we typically require signatures from both parents on our Informed Consent and Confidentiality Notice.

However, in situations where one parent claims sole custody or exclusive authority to consent for mental health treatment, a Declaration of Sole Custody or equivalent legal documentation must be submitted. The onus lies entirely on the presenting parent or guardian to verify whether the signature of the other parent is legally required under applicable family law or custody agreements.

Synapse Mental Wellbeing shall not be held responsible for any dispute arising from the failure to obtain consent from the non-presenting legal guardian or parent.

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Professional Fees:

Fees for psychiatric consultations may vary based on the type of session (e.g., initial diagnostic session versus follow-up medication management). A fee schedule for services can be provided upon request.

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Health Insurance:

Be aware that most insurance companies require authorization to provide them with a clinical diagnosis for benefits to pay for services. Sometimes additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases) are required. This information will become part of the insurance company files and will probably be stored on a computer. Although all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they can share the information with national medical information databanks. It is important to remember that clients always have the right to pay for services themselves to avoid the potential problems described above. Please keep us informed of changes in financial status and insurance or medical assistance eligibility. Clients may be responsible for charges incurred if coverage has changed or lapsed and prior notification is not provided.

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Phone Availability:

The psychiatrist may often not be immediately available by phone due to other obligations. Synapse may provide emergency supportive sessions with any other available mental health professional in cases of immediate need.

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Emergency & Interruption of Service:

In the event of any mental health or substance abuse emergency, we encourage contacting the Synapse reception or calling 112 for immediate assistance.

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Psychiatrist’s Non-Availability:

When the psychiatrist is on vacation or plans to be unavailable for a brief period of time, the name and number of another mental health professional that can be contacted with questions or seen as needed will be provided. In the event of a longer interruption of service, appropriate referrals will be made.

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Client Satisfaction Survey:

Feedback about the services received is welcomed. We are dedicated to improving the delivery of services to clients. A client satisfaction survey is available that may be filled out at any time during or after the completion of psychiatric consultation.

 

Legal Terms

Dispute Resolution:

Any dispute arising out of or in connection with this Informed Consent for Psychiatric Consultation Agreement, or the psychiatric relationship between the client and Synapse Mental Wellbeing, shall be resolved through binding arbitration in Bengaluru, India, in accordance with the rules of the Indian Council of Arbitration.

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Liability:

Synapse Mental Wellbeing is not liable for any indirect, incidental, or consequential damages arising out of use of our services or this Informed Consent for Psychiatric Consultation Agreement.

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Governing Law and Jurisdiction:

This Informed Consent for Psychiatric Consultation Agreement shall be governed by and construed in accordance with the laws of India. Any legal proceedings arising out of or in connection with this Agreement shall be brought exclusively in Bengaluru, India.

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Arbitration:

By signing this Informed Consent for Psychiatric Consultation Agreement, agreement is made to submit any dispute arising out of or in connection with this Agreement to binding arbitration in Bengaluru, India, as described above. The right to a jury trial and to participate in any class action lawsuit is waived.

 

Financial Agreement and Terms

Billing and Payments:

Payment for each session will be expected at the beginning of meetings. In the case of health insurance, any deductible or co-payments will be expected prior to session meetings. Keep in mind that the client (not the insurance company) is responsible for the full payment of fees. Therefore, it is very important to find out exactly what mental health services the insurance policy covers.

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Co-pays & Co-insurance:

Signature below signifies understanding and agreement to pay any co-pays at the beginning of the session on the date it is provided. If health plan benefits are being utilized, responsibility is held for any amount insurance does not cover.

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Cancellation, No Show or Late Arrival:

In general, all clients must provide the psychiatrist with a minimum of 24 hours' notice in the event of a cancellation. Clients will be charged for appointments that are not canceled at least 24 hours in advance and for all no-shows. Clients arriving late will not be provided with an extension of time beyond what was scheduled so as not to disrupt other client appointments. No reduction in fees will result from shortened sessions due to a client’s late arrival.

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Termination:

Additionally, if a client misses two appointments, the psychiatrist has the option to terminate services and refer to another clinic for services.

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Assessments and Reports

Purpose of Assessments:

The assessments, reports, and diagnoses conducted at Synapse are solely intended for internal therapeutic and treatment planning purposes. These evaluations serve as essential tools to formulate personalized treatment plans and interventions designed to support the healing process within our environment.

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Non-Therapeutic Use of Assessments / Reports

It is crucial to understand that the information obtained, including any diagnoses made, is not to be utilized outside the confines of Synapse for any non-therapeutic purposes. These assessments are intended to guide internal treatment planning, therapeutic decisions, and clinical monitoring within the scope of mental health services provided by Synapse. Such documentation will include the following standard disclaimer:

"It is crucial to understand that the information obtained, including any diagnoses made, is not to be utilized outside the confines of Synapse for any non-therapeutic purposes. These assessments are intended to support internal therapeutic and treatment planning processes only. They do not represent legal, forensic, occupational, or medico-legal evaluations unless expressly commissioned and conducted under those terms.

If clients require reports for:

• Legal matters

• Insurance

• Employment or academic accommodations

They should request a separate re-evaluation or summary report specifically suitable for those contexts.

 

Research

Participation in our Research Program may be chosen.

Personal health information will be anonymized, meaning identity will be removed. This anonymized data will be used for research purposes only. It will help measure the effectiveness and efficiency of our treatments and services. Additionally, anonymized data is often used in scientific research publications to share findings with the broader medical community.

There is the option to voluntarily consent to the use of anonymized data for research purposes. Consent can be withdrawn at any time, and data will be removed from our research database. Additionally, redaction of data from any future publications can be requested.

Please note that once anonymized data has been published or submitted for publication, it may not be possible to redact it. This is because published material is generally considered public information.

If there are any questions or concerns about our data privacy practices, please do not hesitate to ask.

 

Consent:

I have read and discussed the above information with my counselor.

I understand the risks and benefits of counseling and the nature and limits of confidentiality.

I have also been informed of helplines to which I can reach out in an emergency when my counselor is not available.

I understand the Privacy Policy.

I understand the Terms of Use.

I understand the Cancellation and Refund Policy.

 

Signature of Client (Date) _____________________________

 

Signature of Counselor (Date) _____________________________

Signature of Client: _____________________________

Date: _____________________________

Signature of Psychiatrist: _____________________________

Date: _____________________________