Counsellor for You

This form is to be used only for email and phone counselling. For face to face counselling, please contact me directly by phone or through my email address.

Once you have registered as a client, please proceed to the payment page. If you have any difficulty registering, do not hesitate to contact me via email or phone. You will receive an acknowledgement email once you are registered.

		* Compulsory Fields
*Choose the type of counselling required		Email Counselling
		Telephone Counselling
		Skype Counselling

*First Name
*Last Name
Title
*Gender
*Age
*Date of Birth
*Marital Status
*Employment
*Address
*City
*Postal Code
*Country
*E-mail Address
*Confirm E-mail Address
Telephone Number
*Are you receiving counselling from anyone?		Yes No
Terms & Conditions		Any client who wishes to work with Dr. Prishnee Datta must agree to the following conditions: by filling out and returning my Client Questionnaire, you indicate that you understand and agree to the terms and conditions stated below: You agree that you have read the section on confidentiality, below and you agree with the terms set out in that section. You understand that I am a psychologist practicing in Belgium and that our relationship is governed by the laws of the country. You agree that you are minimum 18 years of age. You agree that all the information you provide in the Client Questionnaire is accurate, and that no important information has been deliberately omitted. You agree to supply your true full name, address, and phone number on the Client Questionnaire. You understand that if any of this information is inaccurate, it may be a major limitation on my ability to help you. While I am hopeful that our work together will be helpful to you, I cannot guarantee a positive outcome. Like any other therapeutic modality, the effectiveness of online counselling depends greatly on how much of an investment of time and energy you are willing to make. Generally speaking, the more you invest in it, the more you will get out of it. The goal of our exchanges is to help you. If either of us feels, at any time, that working together is not helpful enough to you, either of us is free to terminate our relationship at any time. If you are currently taking medication for any psychological or psychiatric problem (e.g., depression, anxiety), I may ask you for the name, address, and phone number of the physician who has prescribed this medication, as well as your consent for me to contact this physician. I cannot be held responsible for providing services to you in the event of a crisis or emergency situation. I will do my best to continue to provide services as appropriate if a crisis or emergency develops during our work together. Because I’m working long-distance, I do not have access to resources that I would otherwise have in an emergency situation. Thus, you may need to find a local therapist if such a situation arises. I cannot be held responsible for breaches in provision of services to you that are due to my computer malfunctioning, and/or loss of electricity or Internet connection. My phone number is posted on this website; if you don’t hear from me when you expect to, please don’t hesitate to call me at this number. Confidentiality Online: It is never possible to guarantee 100% protection of the confidentiality of either Internet and telephone transmissions. I will do everything possible to protect against any intrusions on my end, and I ask that you do the same. It is my belief that the single biggest threat to confidentiality is a result of sending messages where the confidentiality of your own messages sent to me or mine sent to you is not secure. If you send/receive emails from your work computer, your supervisor or superior may be able to, or is entitled to view these emails. And unless you have your own password-protected email account at home, family members and others with access to your email account may be able to breach your confidentiality. So please make sure that you’re not sending/receiving emails either from your workplace or from an unsecured email account at home. When using your home computer, please make sure that you are the only person with access to your personal email account. In terms of confidentiality problems with telephone sessions, please understand that if you choose to use a cordless or cell phone during a phone session with me, someone with a scanner could possibly hear you talk. To summarize, there are risks to your confidentiality online, as there are in an office setting as well. However, I believe these risks to be extremely small assuming common sense is used and appropriate precautions are taken to protect emails sent and received. There are no other explicit or implicit commitments in our relationship.
*Do you accept the Terms & Conditions?		Yes No