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会员与授权机构管理办法 Management Measures for the Accreditation and Training of Mental Health Managers Membership Guide and Fee Standards (2025 Trial Version) International Mental Health Management Association (China Representative Office) Articles of Association International Mental Health Management Association (China Representative Office) Code of Ethics Psychological Consulting Informed Consent Form Management Measures for the Accreditation and Training of Professional Psychological Counselors
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Psychological Consulting Informed Consent Form

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Psychological Consulting Informed Consent Form

  • Ref Number: IMHMA-RO-ICF

  • Version: 2025-V1.0

  • Effective Date: [March] [22], 2025

Dear Client:

Welcome to the professional services provided by the International Mental Health Management Association (China Representative Office) ______ Workstation (hereinafter referred to as "the Center"). To protect your lawful rights and ensure the effectiveness of the consulting work, please read the following terms carefully before starting the consultation.

I. Nature of Service (Special Notice)

  1. Non-Medical Nature The services provided by the Center fall under the category of "Non-medical Psychological Consulting" and "Mental Health Management."

    • We DO NOT provide medication treatment or conduct medical diagnoses of mental disorders.

    • We ARE NOT QUALIFIED to issue sick leave certificates, psychiatric appraisal reports, or forensic appraisal reports.

  2. Referral Principle According to the Mental Health Law of the People's Republic of China, if the consultant assesses that your condition belongs to a severe mental disorder (such as schizophrenia, bipolar disorder in an acute phase, etc.) or exceeds the consultant's competence, the consultant is obliged to recommend that you seek medical treatment at a medical institution and may terminate the current consulting relationship.

II. Confidentiality and Exceptions

We will strictly abide by professional ethics and laws and regulations to keep your personal information and consulting content strictly confidential. However, in the following "Exceptions to Confidentiality", to protect life safety and comply with the law, we will breach confidentiality and report to relevant departments or guardians:

  1. You have clear ideation, plans, or actions regarding suicide, and the crisis is imminent;

  2. You pose a risk of inflicting serious bodily harm or killing others (including the consultant);

  3. Cases involving minors suffering from sexual assault, abuse, domestic violence, or severe school bullying (pursuant to the Mandatory Reporting obligation under the Law on the Protection of Minors);

  4. Circumstances where laws require disclosure or judicial authorities (courts, police) legally request files.

III. Settings and Fees

  1. Duration

    • Individual Session: 50 mins/session

    • Family Session: 90 mins/session

  2. Fees The level of the consultant you selected is [ _____ ], and the fee is RMB [ _______ ] per session.

  3. Payment Fees must be paid through the Center's official designated account/channel before the session begins. Private transfers to consultants or giving expensive gifts are strictly prohibited.

  4. Appointments & Cancellation

    • If you need to change or cancel an appointment, please notify the staff at least 24 hours in advance.

    • Lateness: If you are late, the session will end at the scheduled time and will not be extended. The full fee will be charged.

    • No-Show: If you cancel temporarily within 24 hours or are absent without a reason, we will charge the full fee for the session to compensate for the reserved time cost.

IV. Crisis Intervention

The Center is NOT a 24-hour emergency facility. If you feel extreme distress, are at risk of losing control, or are in life-threatening danger during non-working hours or between sessions, please take the following measures immediately:

  1. Go to the nearest psychiatric hospital or the emergency department of a general hospital;

  2. Call 110 (Police) or 120 (Ambulance);

  3. Contact your emergency contact person.

V. Special Note for Minors (If Applicable)

If the client is under 18 years of age, this consent form must be signed by a guardian. The consultant will maintain necessary communication with the guardian within the limits of the law (focusing on safety and educational advice). However, provided there is no life-threatening danger, the consultant will strive to maintain the minor's privacy to build a trusting relationship.

VI. Recording

To protect privacy, neither party (including the client and the consultant) may record audio or video privately during the consultation without written permission from both parties. If recording is required for supervision or teaching purposes, the consultant must obtain your written consent in advance, and you have the right to withdraw such consent at any time.

Signature Confirmation

I have read and fully understood the above terms (especially regarding the non-medical nature, confidentiality exceptions, crisis management, and fee rules), and I agree to accept the psychological consulting services of the Center.

Client Name: ____________________ Phone: ____________________

Emergency Contact & Phone: ____________________ (Required for emergency use only)

Date: 20____ / ____ / ____

(Signed by Guardian if Client is under 18)

Guardian Name: ____________________ Relationship: __________ Date: 20____ / ____ / ____

Consultant's Statement: I have explained the contents of this consent form to the client and promise to abide by professional ethics and relevant laws to provide professional psychological services.

Consultant Signature: ____________________ Date: 20____ / ____ / ____