Informed Consent Form

Dear Visitor/Client,
Thank you for your trust in choosing our Psychological Center to provide you with professional counseling services.
As you are the guardian of the client, and the client will receive counseling at our institution, we need your informed consent before commencing relevant counseling work. This requirement is in accordance with the National Professional Standards for Psychological Counselors and relevant national laws and regulations, and is intended to ensure the smooth progress of the counseling process.
Key Information
(The information confirmed prior to this consent form and filled out accurately constitutes the following key components)
Client: ________
Gender: ________
Age: ________
Guardian: ________
Relationship with Client: ________
Contact Information: ________
Does the guardian consent to the client receiving counseling at this institution?☑ Consent to counseling □ Do not consent to counseling
Do you consent to the storage of the following materials during the counseling process?
Audio recording: □ Consent □ Do not consent
Video recording: □ Consent □ Do not consent
Counseling Guidelines
Please read the following counseling guidelines and relevant explanations carefully:
I. Basic Information Requirements
Please fill out the client registration form truthfully. Our center shall not be liable for any consequences caused by incorrect or untrue information due to your personal reasons.
II. Rights and Obligations of the Client
Approach counseling with a positive attitude, and disclose your thoughts and feelings to the counselor honestly without concealment or pretense.
Voluntariness: You have the right to terminate or end counseling, choose your counselor independently, and negotiate with the counselor to revise the counseling plan.
Autonomy: Strive for self-growth and take responsibility for the counseling process. We cannot make decisions on your behalf.
Respect the counselor and relevant staff.
Adhere to the counseling structure. Counseling is a process, and we cannot "cure" issues in a single session. The effectiveness of psychological counseling depends on the joint efforts of both the counselor and the client. (During counseling, you may feel troubled by symptoms or experience symptom recurrence, or recall unpleasant past events that trigger intense emotions. Maintaining a positive, open, and honest attitude during counseling is crucial.)
Abide by the scheduled counseling time. During the counseling session, please set your mobile phone to silent mode or turn it off, and avoid handling personal matters unrelated to counseling.
III. Rights and Obligations of the Counselor
Sincerity: Receive each client warmly, listen patiently, and establish a trusting counselor-client relationship.
Confidentiality: Maintain strict confidentiality of the content discussed during counseling and properly store relevant materials. Do not discuss client-related information casually outside the counseling room.
Respect: Respect the client’s thoughts and wishes, and accept the client’s emotions and feelings.
When the counselor has personal limitations, honestly inform the client and make timely referrals to other professionals.
Avoid dual relationships: The counselor shall not accept gifts from the client, nor establish relationships with the client outside of counseling.
IV. Strict Adherence to Confidentiality Principles
Relevant information from the counseling process—including case records, assessment data, correspondence, and other materials—are classified as professional information. Counselors shall store such information under strict confidentiality. The following are exceptions to confidentiality:
If the counselor identifies that the client poses a risk of harm to themselves or others during counseling, necessary measures shall be taken (e.g., notifying relevant authorities or family members, or consulting with other counselors to prevent accidents). However, the disclosure of private information shall be minimized to the greatest extent possible.
In some cases, counselors may conduct case discussions for professional development, or use cases for teaching, research, or writing purposes. The counselor shall ensure that any information that could identify the client is anonymized in such uses. Additionally, the materials shall only be used by professional psychological counselors, and no disclosure shall occur. If you do not wish your case to be used for these purposes, please inform us in advance.
Additional confidentiality exceptions:(1) The counselor identifies that the client is at serious risk of self-harm, suicide, or harming others;(2) The client has a life-threatening infectious disease that may endanger others;(3) Disclosure is required by law.
V. Counseling Time
On the day of the first counseling session, please arrive 15 minutes in advance to complete psychological assessments and other forms, to ensure counseling efficiency.
Each counseling session lasts 50–60 minutes (depending on the service item). Weekly sessions are recommended. Counseling appointments require booking 2–3 days in advance. If you need to reschedule, please notify our center by phone at least 24 hours in advance and coordinate with the counselor; otherwise, the reservation fee will be deducted.
Reminder for lateness: If the client is late for 30 minutes or less, the missed time will be deducted from the scheduled counseling session; if late for more than 30 minutes, the day’s counseling session will be canceled (the reservation fee will be deducted), and a new appointment will need to be scheduled.
Overtime fee calculation: No additional charge for overtime of 10 minutes or less; overtime of 10–30 minutes will be charged as half an hour of counseling fee; overtime of 40–60 minutes will be charged as one hour of counseling fee.
VI. Termination of Counseling and Referral
During counseling, if the client is dissatisfied with the counselor, they may request to terminate the service or change the counselor. If the counselor deems themselves no longer suitable for providing services for the client’s case, they shall communicate clearly with the client and, with the client’s consent, refer the client to another counselor.
The counselor will conduct a final closing session to summarize the previous counseling process. Fees for the counseling sessions already provided will be calculated in accordance with the previously agreed fee standard, and any remaining counseling fees will be refunded to the client.
VII. Potential Emergency Situations
If the client’s condition is already severe at the start of counseling, the following situations may occur:
Onset of psychotic symptoms;
Acts of suicide, self-harm, or harm to others.
For the above situations, neither the psychological counselor nor our institution shall bear any liability.
VIII. Audio/Video Recording
The psychological counselor may only audio-record, video-record, or demonstrate the counseling process with the client’s written consent. Such recordings help the counselor conduct self-analysis and counseling summaries to improve the effectiveness of services. Meanwhile, the counselor shall manage the audio and video materials confidentially and shall not disclose them to any other entity or individual without the client’s consent.
Please make your selection and sign below according to your wishes.
To facilitate follow-up psychological counseling services, it is necessary to register the client’s real name, contact information, emergency contact person, and other details. Your personal information—including all psychological counseling materials—will be stored exclusively by the counselor or our institution. Without your consent, such information shall not be disclosed to any other entity or individual.
IX. Special Notes
If you are booking counseling on behalf of another person, or have doubts about your own counseling, please be sure to explain the situation. An assessment will be conducted before confirming whether to proceed with the booking.
Counseling effectiveness depends on the client’s active cooperation; therefore, the client must attend counseling voluntarily.
Do not make major decisions during the counseling period, including but not limited to divorce or resignation.
If you interrupt the counseling process due to personal reasons, you shall bear all resulting consequences.
X. Final Interpretation Right
Our center reserves the final right to interpret this agreement.
I (including the guardian) have read all the above content in full. The information I have provided is true and accurate. If any information is untrue, I (including the guardian) agree to bear the corresponding legal consequences. I fully understand the content above and voluntarily abide by this psychological counseling agreement.
This agreement shall take effect on the date of signature/submission and payment. (For online submission, the mobile phone IP