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Confidentiality Agreement
Confidentiality Agreement
Ambika Bhardwaj
Phone: +91 9646641994
Email : ambikabhardwaj19@gmail.com
Dear Client,
Please read the following carefully, and sign or initial as indicated. Note that I, as a
psychotherapist, am ethically bound by the terms of this agreement. As confidentiality is critical
to the psychic safety and integrity of this professional relationship, this document, when filled
out and signed by you, makes clear the limitations and permissions around the revealing of any
information shared between us. You may, by request, change the terms of this agreement at any
time, and I will provide you with a new form to complete. Granting or withholding any
permissions contained in the document will in no way affect the quality, quantity or content of
our relationship.
Please print this document, fill it out completely, scan and return the digital copy to me. Keep
original for your records.
____________________________ _____________
Name (DD/MM/YYYY)
I agree fully to the above, and I may choose at any time to change the terms of this agreement by
modifying this or creating a new one, and providing a copy to the psychotherapist. The new
agreement will go into effect when received by the psychotherapist.
_____________________________ _____________________
Signature Date DD/MM/YYYY