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Consent Form

Pair/Group Therapy

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Step 1 of 2

Estimated completion time: 10min


From the moment the client gets in touch with us, everything they say is confidential.
Our confidentiality policy is held for the client's own protection, and for the protection of vulnerable adults, teenagers and children. Therefore, there will be no disclosure of the client's case or engagement.

The only limit to our confidentiality policy is when the client or others are at risk of serious harm, life threat, safety threat, or criminal activity. This limit to our confidentiality policy includes but is not exclusive to reports of child-, elder-, and dependent adult- abuse, which can be physical-, sexual- or emotional- abuse; and expressed threats of violence.

As the client's Healthcare Representative, we are mandated people, i.e. we are legally obliged to report to Tusla (National child protection, early intervention and family support services Agency) any disclosure or concern of abuse or neglect, that is physical, sexual or emotional, and that occurs to anyone who is now under 18 years of age, or who was under 18 years of age at the time of the experienced abuse if the perpetrator has access to other children. Please note that, therefore, the limit to our confidentiality policy also includes retrospective reports of abuse, for example, if the client is an adult now and they disclose having been abused as a child.


  • If you are in crisis, you can always text HELLO to 50808 or Call Samaritans using their freephone 116 123

  • Alternatively, if you have a risk emergency and need to reach us outside of hours, you may use our emergency phone contact and WhatsApp, 0899 72 42 30.

  • Please note that we are not an emergency service, such as hospitals, psychiatric units, Accident & Emergency (A&E), ambulances, police, fire brigade, or 24/7 services. Therefore, we can only help you within our scope of work availability and make relevant referrals for yourself.

Data Protection Policy

Dublin Mind Clinic collects and stores your personal information safely for the purpose of delivering the services provided by Dublin Mind Clinic to you as our client. In addition, your anonymous data is solely used for the purposes of research and development of our services.

Dublin Mind Clinic keeps your data due to legal requirements for seven years from the date you last engaged with our services, after which all of your data will be destroyed to protect your confidentiality further. In the case of clients who are minors, their data will be kept until they reach 24 years of age, after which point their data will also be destroyed.

Engagement in Telehealth (Online Therapy)

Telehealth is the distribution of health-related services and information via electronic information and telecommunications technologies to support long-distance clinical health care, client and professional health-related contact, care, advice, education, intervention, monitoring, remote admissions, and health administration. Telehealth technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.

Dublin Mind Clinic takes your safety and confidentiality seriously. This is why we invest on the highest standards of professional telehealth platforms, which are GDPR and HIPAA compliant, and which include encryption of all data involving your video therapy connection. In addition, none of the messages exchanged or videos used during therapy are recorded; all video therapy data is automatically destroyed after each online session.

As much as Dublin Mind Clinic ensures your safety and confidentiality from our end, it is also crucial that you take responsibility for ensuring your safety and confidentiality from your end. Therefore, our online therapy requires that you: Use a private device (not a public access device); use a private network (not a shared network); do not leave your online therapy screen open when you move away from your device; consider who may have access to your device information; ensure a private and confidential space for your online therapy; and a reliable high speed internet connection.


Sessions are typically arranged on a weekly basis and last up to 50 minutes. The recommended duration for psychotherapeutic treatment is of 12 sessions - whilst considering a shorter or longer period, depending on the client’s needs.

Psychotherapy does not only treat present symptoms, but it also treats the origins of symptoms, in light of preventing their future emergence. In addition, Psychotherapy enables the client to “train” and practice their personal skills and abilities, to develop long-term coping strategies and resilience.
Therefore, Psychotherapy is based on a joint work between therapist and client; which in turn makes it crucial that the client commits fully to their treatment and that they are consistent in it.

It is not tolerated that sessions go overtime, as this jeopardizes the time-sensitive work that Dublin Mind Clinic commits to the development of its services for all of our clients. It is also not tolerated that clients block book their sessions in advance, as this jeopardizes other clients’ possibility to adhere to Dublin Mind Clinic’s weekly availability.


  1. Sessions must be paid in advance. You can pay your session fee via card at the reception before your session start or by paying the invoice in advance.

  2. You must first pay any outstanding session amounts before a next session can be booked.

  3. If you arrive at your session and are unable to pay any outstanding and/or current fees, it will be necessary to reschedule your session for a later date.

  4. Card payment: For card payments, please have your card ready for payment at reception before your session start. It is recommended to have a backup payment method in case the card is not accepted or if there are any technical issues.

  5. We do not accept cash or check payments.

Fees are not to be accumulated and paid at a later stage. Therefore, it is the client’s responsibility to ensure they have the required fee for their appointment.

Dublin Mind Clinic fees are competitive and take into consideration individual clients’ financial needs.

Therefore, the price of each Couples Therapy session is €100 and each Group Psychotherapy session is €50 per person.


Late Cancellations

Late cancellations within less than 48 hours in advance of the time of your upcoming session are charged half-price:

  • €50 for Couples Therapy sessions

  • €25 per person in Group Therapy sessions

Otherwise, a minimum of 48 hours’ notice in advance of your appointment time is required in order to cancel your session free of charge.


No Show

If no effort is made to cancel your appointment 48 hours in advance of the time of your appointment, OR if you cancel your appointment within 2 hours or less from your appointment time, you will be charged in full for your missed session:

  • €100 for Couples Therapy sessions

  • €50 per person in Group Therapy sessions

Otherwise, a minimum of 48 hours’ notice in advance of your appointment time is required in order to cancel your session free of charge.

Free First-Time Consultation (for Psychotherapy only)

This service is a once-off service for Psychotherapy only. If you do not attend your booked free first-time consultation, you can no longer use it for your next booking(s), and future sessions are subject to the regular prices and terms.


Being late

If you are late for your appointment, we will do what we can to give you your full treatment time. However, treatment time may be shortened to allow us to finish on time for the next client.


First Appointment

You may call or e-mail Dublin Mind Clinic to make your first appointment. Although GP referrals are appreciated, they are not a requirement and you may make an appointment directly with us.


Housekeeping (in-person Therapy)

Please adhere to and respect our housekeeping rules listed below:

  1. No Photography

  2. No video recording / video calls

  3. No vehicles and animals inside the premises (except service animals)

  4. No property damaging

  5. No children are left unattended.

  6. Keep sound to a minimum to respect all sessions. Mute electronic devices and avoid calls while on the premise.

  7. Food and drinks: No food or beverages are allowed inside Dublin Mind Clinic therapy rooms, with the exception of a bottle of water that may be taken with you to your session.

  8. No disruption to ongoing sessions (i.e. knocking, door opening)

  9. All visitors must report to the reception.

General Notes

Please note that we do not provide any advice regarding clients’ health insurances and taxes and clients’ eligibility to claim for their fees. It is the client’s responsibility to inform themselves with their health insurance about whether they are or not eligible to claim their fees.

Please be aware that Dublin Mind Clinic cannot answer to time-sensitive queries or concerns from clients that emerge between or outside of their sessions. Therefore, we ask that such time-sensitive queries or concerns are brought to your next session, where they can be addressed and planned.

Permission to be contacted

Please let us know if you give us permission to contact you between or outside of sessions where necessary or in your interest.


I hereby consent Dublin Mind Clinic to contact me via:

How do you identify yourself?

At Dublin Mind Clinic, your first consultation with us is FREE of charge.

In order to make the most out of your free first session, we require filling the questionnaire & consent form before booking an appointment.

To commence therapy, we are legally required to collect certain information which may be seen as 'sensitive protected data' under EU (GDPR) laws. For this, we kindly ask for your consent.

This process takes only ~20 min to complete but allows the therapist to study your case and in turn offer a more time-efficient experience for you.

Please note¹: for couples therapy, we require both / all participants to submit their questionnaire and consent forms individually. If the partner(s) are not present while viewing/filing this consent form and questionnaire, it is possible to have them fill out their(s) at a later point. An individual Link will be provided during the process.

Please note²: this form is optimised for PC/Mac browser. If you have difficulties completing on your phone/tablet, we kindly ask you to try a browser on your PC/Mac.

Which type of therapy are you looking for?

Permission to contact other professionals
As a means to supporting you with our best service delivery, Dublin Mind Clinic may occasionally need to contact your GP or Psychiatrist to liaise with them to ensure the achievement and continuity of your best outcomes.

Therefore, please let us know if you give us permission to contact your:


Research and Training at Dublin Mind Clinic (Optional)

At Dublin Mind Clinic, we enable staff training and development in order to maximize our team’s professional excellence. In addition, we facilitate research projects to help maximize and update our empirical work further.

For the purposes of training, it may be that you might be asked for permission for one of our staff members to observe your session. For the purposes of research, it may be that you might be asked for permission for your stored data to be studied. Please bear in mind that, all stored data is anonymized so that it cannot be linked to any client from whom the data is collected. Therefore, stored data is never identifiable and client identity is confidentially protected at all times. Furthermore, any research studies which are carried out are firstly subject to full ethical approval from a trusted Academic Research Ethics Committee.

Please note that you are under no obligation to consent to this research and training section of our consent form. Your decision to take part in this section is voluntary and it will in no way affect the services provided to you at our clinic.
If you are happy to have one of our staff members observe some of your sessions, please tick the box below (optional).

If you are happy to have one of our staff members observe some of your sessions, please tick the box below (optional).

If you are happy for your confidential and anonymized stored data to be studied for research purposes, please tick the box below (optional).

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