Consent-to-treat template

This is a template. Modify each clause to match your clinic's policy and have a qualified lawyer or your regulator review before adopting.

Patient information

• Patient name (as on CNIC): _____________________________
• CNIC or ID number: ________________________________________
• Date of birth: ______________________________________________
• Emergency contact — name & phone: __________________________

1 · Nature of the service

I understand that I am receiving psychotherapy from [Clinic Name] for the purpose of assessment and treatment of a mental-health concern. I understand that psychotherapy is a collaborative process and outcomes cannot be guaranteed.

2 · Confidentiality

I understand that everything I share is confidential except in these situations, which the clinician is legally / ethically required to disclose: risk of harm to self or others, safeguarding of a child or vulnerable adult, or when required by a court order.

3 · Records

I understand that my clinician keeps session notes as required by law. These records are stored securely and are accessible only to the treating team. I may request a copy of my records at any time.

4 · Fees and cancellation

Session fee: PKR __________________. Cancellations made 24+ hours before the session are refunded in full. Cancellations under 3 hours or no-shows may be charged the full session fee.

5 · Consent

I have read the above, my questions have been answered, and I consent to treatment.

• Patient signature: ____________________________ Date: ___________
• Clinician signature: ___________________________ Date: ___________