A starting point to adapt to your placement's policy and language, not a legal document. Read it with the client, in Urdu or their language, and answer their questions before they sign. Print with your browser's Print command; the site's menus are left off the paper.

Consent and confidentiality

Trainee: ____________________ Placement: ____________________ Date: ____________

Who you are seeing

Name and role of the trainee
That the trainee is supervised, and by whom

What will happen

What the sessions involve and roughly how many
Tests or questionnaires that may be used

What is kept

What is written down, where it is kept, and who can see it
That case discussions with the supervisor, and any report for the trainee's degree, leave out names and identifying details

When confidentiality has limits

A serious risk to the client's life or safety
A serious risk to someone else, including a child
When a court or the law requires it
In those cases, who would be told, and that the client would be told first where possible

Your choices

That the client can ask questions at any time
That they can stop at any time, and it will not affect other care at this service

Consent

I have read or been read this sheet, and my questions were answered
I agree to take part

Client (or parent or guardian): ______________________________ Date: ______________

Trainee: ______________________________ Date: ______________

Date: ______________________________ Date: ______________

Template from PsychologyOrbit (https://psychologyorbit.com/templates/consent-and-confidentiality). Free to print and adapt. No client names, phone numbers, CNIC or hospital numbers, or dates of birth.