Informed Consent for Psychological Services

Welcome. This document explains the nature, risks, and benefits of the psychological services offered in my private practice, as well as your rights and responsibilities as a client. Please read this information carefully and ask any questions you may have before signing. By signing this document, you acknowledge that you understand the information provided and agree to participate voluntarily in services.

About the Psychologist

Name: Dennis Daupert, PhD
License: Licensed Psychologist, State of Indiana
License Number: 20042900A
Additional information regarding my training and professional background is available on my website

Services Offered

I provide individual and couple Past Life Depth therapy for adults (ages 18+)
Areas commonly addressed include, but are not limited to, anxiety, self-esteem concerns, childhood trauma, impostor syndrome, relationship conflict, and personal or existential concerns.
My clinical approach integrates:
- Past Life Regression Therapy / Past Life Depth Therapy (PLDT)
- Internal Family Systems (IFS)-informed interventions
- Mindfulness-based and experiential techniques
I do not provide:
- Medication management or prescribing services
- Court-ordered, forensic, or custody-related evaluations

Evaluation and Appropriateness of Services

The initial free 30-minute consultation is a screening conversation intended to determine whether my services, including regression-based interventions, are appropriate for your presenting concerns. Following this consultation, prospective clients complete a confidential intake questionnaire. Complete and accurate responses are essential, as certain psychological or medical conditions may make regression-oriented work inappropriate or clinically contraindicated.

Conditions that may preclude or limit the use of PLDT include, but are not limited to: active psychosis, unmanaged bipolar disorder, severe dissociation, active substance dependence, significant cognitive impairment, or acute safety concerns. When such factors are present, alternative treatment or referral may be recommended.

At the beginning of each PLDT session, a brief clinical assessment is conducted to clarify objectives and evaluate current psychological stability. Ongoing assessment occurs throughout treatment. At any point, we may mutually determine that a different therapeutic approach or provider is more appropriate. You may discontinue services at any time.

Description of Past Life Regression Therapy

Past Life Regression Therapy / Past Life Depth Therapy (PLRT/PLDT) is provided within the scope of licensed psychological practice and is offered as an experiential and meaning-oriented intervention, not as a determination of historical fact. Experiences that arise during sessions are understood and addressed clinically as imaginal, symbolic, narrative, emotional, or autobiographical phenomena.

No assertion is made that material accessed during regression reflects literal past lives. Therapeutic focus is placed on the client's current psychological functioning, emotional processing, insight, and behavioral integration, consistent with accepted psychotherapy goals.

PLDT is used only when clinically appropriate and is integrated with established psychological frameworks (e.g., Internal Family Systems‐informed and mindfulness-based approaches). It is not a replacement for medical care, psychiatric treatment, or evidence-based interventions where those are indicated.

Your active participation is required. Interventions vary depending on treatment goals and may involve emotionally intense material. As with all psychotherapy, specific outcomes cannot be guaranteed.

Benefits and Risks

Potential Benefits

Psychotherapy, including PLDT when appropriately applied, may contribute to:

Improved emotional regulation and insight
Reduction in symptom-related distress
Increased psychological flexibility and meaning-making
Improved coping skills and relational functioning

Potential Risks and Limitations

Emotional discomfort, distress, or fatigue may occur during or after sessions
Temporary increases in anxiety, sadness, or other affective states are possible
Imaginal or narrative material accessed during experiential work may feel vivid or personally significant but should not be interpreted as factual memory without corroboration
As with all psychotherapy, improvement is not guaranteed

You are encouraged to ask questions, voice concerns, and seek a second opinion at any time.

Confidentiality and Its Limits

All information disclosed in therapy is confidential and protected by professional ethics and Indiana law, with the following exceptions:
- Mandatory reporting: Suspected abuse or neglect of a child, elder, or dependent adult.
- Risk of harm: If there is a reasonable belief of imminent risk of serious harm to you or others.
- Legal requirements: Compliance with a valid court order, subpoena, or statutory obligation.
- Professional consultation: Consultation with other licensed professionals for clinical purposes, with reasonable efforts made to avoid identifying information.
Clinical records are maintained in accordance with Indiana law and APA standards. You may request access to your records, subject to legal and ethical limitations. Questions about confidentiality are welcome at any time.

Fees and Structure of Services

Past Life Depth Therapy is not structured as standard weekly psychotherapy. Sessions are longer, more intensive, and typically fewer in number.

Fees

Initial PLDT session   $495
Ongoing PLDT Sessions   $330
Consultation Sessions   $165 per hour

An initial three-hour PLDT session is $495. That includes: a pre-session consultation up to an hour; the regression itself up to two hours; a post-session debriefing.

We schedule a followup consultation one to two weeks later to keep tabs on your progress. It's part of what makes the therapy effective. If your issue is completely resolved by then, no further sessions are scheduled. If needed, we'll set aside additional time for full regression work.

Payment Policies

Accepted forms of payment include major credit/debit cards, FSA, and HSA cards
Fifty percent (50%) of the fee is due at the time of scheduling
The remaining balance is due at the time of service
Cancellations with less than 48 hours' notice result in forfeiture of the initial payment, except in limited circumstances
Accounts unpaid after 60 days may be referred for collection

Insurance Reimbursement

Insurance providers generally do not reimburse for psychotherapy sessions that exceed standard 45‐90 minute formats. As such, PLDT services are self-pay.

My Professional Responsibilities

I provide services consistent with the APA Ethical Principles of Psychologists and Code of Conduct and the laws and regulations governing the practice of psychology in Indiana. My responsibilities include:

Practicing within the scope of my education, training, and licensure
Clearly distinguishing psychotherapy from spiritual counseling, coaching, or medical treatment
Maintaining accurate clinical records
Protecting client confidentiality and privacy
Making referrals when a client's needs exceed my scope of practice or when another level of care is indicated

Contact and Emergencies

Non-emergency messages will be returned within approximately 24 hours, excluding weekends and holidays.
In an emergency, call 911 or 988 (Suicide & Crisis Lifeline).
In the event of my extended absence, referral information will be provided.

Client Acknowledgment of Understanding and Consent

By signing below, I acknowledge and agree that:

I am voluntarily seeking psychological services from Dennis Daupert, PhD, a licensed psychologist in the State of Indiana.

I understand that Past Life Regression Therapy / Past Life Depth Therapy (PLRT/PLDT) is provided as a form of psychotherapy using experiential, imaginal, and meaning-oriented techniques, and that experiences accessed during sessions are not presented as literal or historical facts.

I understand that PLDT may involve emotionally intense material and that no specific outcomes or results are guaranteed.

I understand that PLDT may not be appropriate for all individuals and that my therapist will continuously assess appropriateness and may recommend alternative treatment or referral if indicated.

I understand the limits of confidentiality, including mandatory reporting, safety-related disclosures, and legal requirements.

I understand the fee structure, payment policies, and cancellation terms associated with these services.

I understand that I have the right to ask questions, seek clarification, refuse or discontinue services at any time, and seek a second professional opinion.

By signing, I affirm that I have read the full Informed Consent document, that my questions have been answered to my satisfaction, and that I consent to participate voluntarily in psychological services as described.

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Informed Consent for Psychological Services

Name: Dennis Daupert, PhD

License: Licensed Psychologist, State of Indiana

License Number: 20042900A

Additional information regarding my training and professional background is available on my website

Services Offered

I provide individual and couple Past Life Depth therapy for adults (ages 18+)

Areas commonly addressed include, but are not limited to, anxiety, self-esteem concerns, childhood trauma, impostor syndrome, relationship conflict, and personal or existential concerns.

My clinical approach integrates:

Past Life Regression Therapy / Past Life Depth Therapy (PLDT)

Internal Family Systems (IFS)-informed interventions

Mindfulness-based and experiential techniques

I do not provide:

Medication management or prescribing services

Court-ordered, forensic, or custody-related evaluations

Improved emotional regulation and insight

Reduction in symptom-related distress

Increased psychological flexibility and meaning-making

Improved coping skills and relational functioning

Potential Risks and Limitations

Emotional discomfort, distress, or fatigue may occur during or after sessions

Temporary increases in anxiety, sadness, or other affective states are possible

Imaginal or narrative material accessed during experiential work may feel vivid or personally significant but should not be interpreted as factual memory without corroboration

As with all psychotherapy, improvement is not guaranteed

You are encouraged to ask questions, voice concerns, and seek a second opinion at any time. Confidentiality and Its Limits

All information disclosed in therapy is confidential and protected by professional ethics and Indiana law, with the following exceptions:

Mandatory reporting: Suspected abuse or neglect of a child, elder, or dependent adult.

Risk of harm: If there is a reasonable belief of imminent risk of serious harm to you or others.

Legal requirements: Compliance with a valid court order, subpoena, or statutory obligation.

Professional consultation: Consultation with other licensed professionals for clinical purposes, with reasonable efforts made to avoid identifying information.

Clinical records are maintained in accordance with Indiana law and APA standards. You may request access to your records, subject to legal and ethical limitations. Questions about confidentiality are welcome at any time.

Accepted forms of payment include major credit/debit cards, FSA, and HSA cards

Fifty percent (50%) of the fee is due at the time of scheduling

The remaining balance is due at the time of service

Cancellations with less than 48 hours' notice result in forfeiture of the initial payment, except in limited circumstances

Accounts unpaid after 60 days may be referred for collection

Insurance Reimbursement Insurance providers generally do not reimburse for psychotherapy sessions that exceed standard 45‐90 minute formats. As such, PLDT services are self-pay.

My Professional Responsibilities I provide services consistent with the APA Ethical Principles of Psychologists and Code of Conduct and the laws and regulations governing the practice of psychology in Indiana. My responsibilities include:

Practicing within the scope of my education, training, and licensure

Clearly distinguishing psychotherapy from spiritual counseling, coaching, or medical treatment

Maintaining accurate clinical records

Protecting client confidentiality and privacy

Making referrals when a client's needs exceed my scope of practice or when another level of care is indicated

Contact and Emergencies

Non-emergency messages will be returned within approximately 24 hours, excluding weekends and holidays.

In an emergency, call 911 or 988 (Suicide & Crisis Lifeline).

In the event of my extended absence, referral information will be provided.

Client Acknowledgment of Understanding and Consent

By signing below, I acknowledge and agree that:

I am voluntarily seeking psychological services from Dennis Daupert, PhD, a licensed psychologist in the State of Indiana.*

I understand that Past Life Regression Therapy / Past Life Depth Therapy (PLRT/PLDT) is provided as a form of psychotherapy using experiential, imaginal, and meaning-oriented techniques, and that experiences accessed during sessions are not presented as literal or historical facts.*

I understand that PLDT may involve emotionally intense material and that no specific outcomes or results are guaranteed.*

I understand that PLDT may not be appropriate for all individuals and that my therapist will continuously assess appropriateness and may recommend alternative treatment or referral if indicated.*

I understand the limits of confidentiality, including mandatory reporting, safety-related disclosures, and legal requirements.*

I understand the fee structure, payment policies, and cancellation terms associated with these services.*

I understand that I have the right to ask questions, seek clarification, refuse or discontinue services at any time, and seek a second professional opinion.*

By signing, I affirm that I have read the full Informed Consent document, that my questions have been answered to my satisfaction, and that I consent to participate voluntarily in psychological services as described.

You are encouraged to ask questions, voice concerns, and seek a second opinion at any time.

Confidentiality and Its Limits

Insurance Reimbursement

Insurance providers generally do not reimburse for psychotherapy sessions that exceed standard 45‐90 minute formats. As such, PLDT services are self-pay.

My Professional Responsibilities

I provide services consistent with the APA Ethical Principles of Psychologists and Code of Conduct and the laws and regulations governing the practice of psychology in Indiana. My responsibilities include:

I am voluntarily seeking psychological services from Dennis Daupert, PhD, a licensed psychologist in the State of Indiana.

I understand that Past Life Regression Therapy / Past Life Depth Therapy (PLRT/PLDT) is provided as a form of psychotherapy using experiential, imaginal, and meaning-oriented techniques, and that experiences accessed during sessions are not presented as literal or historical facts.

I understand that PLDT may involve emotionally intense material and that no specific outcomes or results are guaranteed.

I understand that PLDT may not be appropriate for all individuals and that my therapist will continuously assess appropriateness and may recommend alternative treatment or referral if indicated.

I understand the limits of confidentiality, including mandatory reporting, safety-related disclosures, and legal requirements.

I understand the fee structure, payment policies, and cancellation terms associated with these services.

I understand that I have the right to ask questions, seek clarification, refuse or discontinue services at any time, and seek a second professional opinion.