informed consent & statement

This form is to inform you about the mental health services offered by Insight-EQ and to obtain your consent for receiving these services. Please read this form carefully and ask any questions you may have before proceeding to complete Form B: Client Registration & Clinical Intake Form (if you are opting for our Counseling & Psychotherapy services). For further inquiries, reach out to us at

Description of Services
The services include counseling and psychotherapy, and may include assessment, diagnosis, treatment planning, consultation, referral, or other interventions as appropriate.

The goals and methods of the services will be discussed with you in the first session and agreed upon before the start of the treatment. You have the right to participate in the decision-making process and to consent or decline any specific service or intervention. You also have the right to withdraw your consent at any time without affecting your right to receive other services. However, it is advisable to discuss the reasons for withdrawal from services prior to acting on the decision.

The services are expected to benefit you by helping you cope with your mental health issues, improve your well-being, and enhance your functioning. However, there are no guarantees that the services will achieve the desired outcomes. There may also be some risks or discomforts associated with the services, such as experiencing unpleasant emotions, recalling distressing memories, facing difficult issues, or making changes that affect your relationships. You are encouraged to discuss any concerns or questions you may have with your therapist at any time.

Informed Consent for Online Therapy Services
Online therapy involves the use of electronic communications to enable mental health professionals to connect with individuals using interactive video and audio communications. Online therapy includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

Relationship Rules
The relationship between you and your therapist is a professional one that is based on trust, and confidentiality. It is not a social or personal one and it does not involve any sexual or romantic contact. You are expected to attend the scheduled sessions on time, pay the agreed fees, and follow the policies and procedures of the service as stated in the Statement of Policies & Procedures document. Your therapist is expected to provide the services in a competent, ethical, and respectful manner.


The information you share with your therapist will be kept confidential and will not be disclosed to anyone without your written permission, except as required or permitted by law. Some of the situations where your therapist may have to disclose your information without your consent are:

  • If you pose a serious threat to yourself or someone else
  • If you disclose abuse or neglect of a child, an elderly person, or a dependent adult
  • If you are involved in a legal proceeding and InsightEQ Consultancy is ordered by a court to release your information
  • If you file a complaint or lawsuit against your therapist at InsightEQ Consultancy or their employer
  • If your therapist at InsightEQ Consultancy needs to consult with another professional for supervision or guidance

Your therapist at InsightEQ Consultancy will make every effort to protect your privacy and confidentiality in these situations and will inform you if they have to disclose your information.

Rights with Respect to Online Therapy
I understand that I have the following rights with respect to online therapy:

  • The laws that protect the confidentiality of my personal information also apply to online therapy. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
  • I understand that the dissemination of any personally identifiable images or information from the online therapy interaction to other entities shall not occur without my written consent.
  • I understand that I have the right to withhold or withdraw my consent to the use of online therapy in the course of my care at any time, without affecting my right to future care or treatment.
  • I understand that there are risks and consequences from online therapy, including but not limited to the possibility, despite reasonable efforts on the part of the therapist, that: the transmission of my personal information could be disrupted or distorted by technical failures; the transmission of my personal information could be interrupted by unauthorized persons; and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons.
  • I understand that if my therapist believes I would be better served by another form of intervention (e.g., face-to-face services), I will be referred to a mental health professional who can provide such services in my area.
  • Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may not improve, and in some cases may even get worse.