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PERSONAL DATA
INTAKE FORM

CEDRIC DSOUZA 
Psychologist

 MA Clinical Psychology 

Diploma in Counseling (TISS) 

Diploma in Human Resource Management(Symbiosis) 

Masters in Personnel Management 

Masters in Commerce 

 Welcome to the Counseling practice of Mr. Cedric Dsouza.

Mr. Cedric Dsouza’s practice seeks to offer professional counseling

to all who seek counseling service

and offers a spiritually centered approach for those with spiritual beliefs. 

Limitations of Confidentiality:

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It is understood (and agreed) that all statements, whether written or verbal,

with your counselor/lay counselor are of a confidential nature and

ethically cannot be disclosed without written consent.

The following exceptions will result in confidentiality being waived. 

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  1. We reserve the right to report child abuse or suspicion of child abuse of any type to the proper authorities and/or the right to cause a report of child abuse to occur. 

  2. We reserve the right to disclose to the appropriate person, agency or civil authorities any harm that a person may attempt or desire to do to one’s self or to others. 

  3. To insure the highest quality process, as a rule your counselor, if under supervision, will consult with their supervisor, regarding your therapy. 

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Fees:

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Regular session fees are Rs 800 for individuals and Rs1200 for couples

and sessions run for per 60 minutes.

Approximately ten percent (10%) of practice is reserved for low income individuals

in order to maximize the availability of services to all.

Online Payment is mandatory for booking appointments 

Cancellations or Reschedules:

 

In the event you need to reschedule or cancel

an appointment please call the day before

your scheduled appointment to avoid

being charged for the session.

 

This also allows us to reschedule others

who are waiting. 

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Late Policy:

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If you expect to be late for your appointment 

please call your counselor.

Clients more than 15 minutes late to

their scheduled appointment may forfeit that

scheduled time.

 

Please contact your counselor if you expect to be late.

It is the client’s responsibility to be on time

and get full use of their scheduled appointment. 

 

Appointments missed or not cancelled

the day before(24 hours in advance)

will be charged the regular session fee.

This must be paid at the next session. 

PERSONAL DATA FORM

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