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Disclosure Statement

Sky Counseling & Consultation Tokyo – Psychotherapy Information Disclosure Statement 

(Updated on October 17, 2023)


Welcome and thank you for choosing Sky Counseling and Consultation Tokyo. This packet includes the information we will need to begin counseling.  Please read, sign, and date all the forms where indicated.



Each counselor at Sky Counseling & Consultation Tokyo has different qualifications and background. Please check with each counselor if you have any questions. 


Counseling Services: 

- We provide counseling services for middle and late childhood, adolescents, adults, couples, and families. Each counselor offers a different range of services. Sky Counseling & Consultation Tokyo offers assistance for a broad range of mental health issues and concerns. 

- Our services do not constitute medical practice. 

- If you are currently seeing a psychiatrist, please obtain a permission from your doctor regarding seeing a counselor at our center.

 -Your counselor may suggest you to visit psychiatrists when she/he/they believes you are in imminent danger to yourself or others.

-Counselors are neither giving you advice nor providing you the answer of the issue you are facing. We support you to find your answer through counseling by utilizing specialized knowledge based on extensive training of counseling.  

- The goal of counseling is to help you improve. Examples of possible improvements are: reducing depression or anxiety, improving relationships, raising self-awareness, etc. 

- Goals will be determined jointly by client(s) and counselor and we will reevaluate those goals as necessary. We provide a safe and supportive environment in which to attain your goals.

- Approaches that counselors use differ depending on the counselor. Please ask your counselor if you have any questions. 


Non-Discrimination Policy:

No client shall be subject to discrimination because of culture, race, color, national origin, sex, gender, age, religion, marital status, class, and such, or the presence of any physical, psychological or physical challenges. 


Informed Consent:

- Counseling is one approach out of many you may choose to create change in your life. Counseling can have benefits and risks. Counseling sometimes involves discussing unpleasant aspects of your life, and you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, helplessness, etc. On the other hand, counseling leads to better relationships, improved feelings about yourself, and decreased negative feelings or stress. 

- Some clients require only a few sessions while others need long-term counseling. You have the right to terminate counseling at any time; however, concluding therapy with ongoing unresolved issues may result in a reoccurrence and even worsening of symptoms. It is for this reason we encourage you to talk with your counselor directly if you are dissatisfied with the services you received, or if you are intending to discontinue appointments. These conversations can offer an opportunity for growth and therapeutic process no matter the decisions you make. We are also able to refer you to a different counselor. If you feel uncomfortable talking to your counselor directly, you are welcome to contact the director of our center by email at



Your right of confidentiality is essential to any therapeutic relationship. No information about you, including the fact that you are a client of ours, will be released to anyone without your written consent except in the following situations.


  • in case of abuse or neglect of a child or vulnerable adult

  • if you are in imminent danger of harming yourself, or another person

  • when required by law enforcement (court or police)

  • when consultation with colleagues is needed while your identity is adequately protected (i.e. using initials). 

  • If we see you in outside of therapy (e.g. in the grocery store), we will protect your confidentiality by not acknowledging that we know you, but you are free to initiate communication if you choose to do so.


Diagnosis and Prescription

Under Japanese law, counselors are not allowed to diagnose or prescribe a medication for clients. If you need diagnosis or prescription, we encourage clients to see a psychiatrist or visit a medical institution. We are not affiliated with any medical institution, but we are happy to share information we have regarding psychiatrists. 


Services at Sky Counseling & Consultation Tokyo are not covered by Japanese National Health Insurance. If you have overseas insurance, please contact your health insurance company for specific information and verify your insurance eligibility prior to your first visit. We are able to provide statements in English or Japanese of all fees paid at our center if you need it for the reimbursement of your insurance.

Distance Counseling:

  • We use HIPPA (The Health Insurance Portability and Accountability Act) compliant platform for online counseling. 

  • Recording any part of your sessions in any format (audio, video, or visual) are prohibited due to the potential risk of breaching confidentiality as well as to maintain safety for both clients and counselors. 

  • For distance counseling, we require payment in advance. Please make payment by 5pm the day before your scheduled session, or if your appointment is on a Monday, by 5pm the day before the previous business day.

  • If there are the network errors or bad signals during the online session, your counselor may switch the platform to alternative one or voice chat if necessary. We are unable to provide phone counseling. 

  • You are responsible for understanding the potential risks of confidentiality being breached through unencrypted, lack of password protection or leaving information on a public access computer in a library or internet café, for example. 

  • Confidentiality could be breached in transit by hackers or internet service providers by accessing your computers or account.

  • When you have an online counseling, please be extra careful that others cannot see your screen or hear your conversation. We are not able to have counseling when you are in public places. Please make sure to secure a private space before your participation.

  • You are responsible for securing your computer hardware, internet access points, email and passwords that are encrypted and secured. 

  • You need to determine who has access to your computer and electronic information from your location. This may include family members, co-workers, friends, and whomever you may share your computer with. 

  • We would like to ask you to be aware that the possibility of misunderstanding may be higher via telephone, email or video due to limited visual input. Please be informed that your counselor may ask for clarifications at times.

  • When your counselor determines that online counseling may not be appropriate, they will explain. Please discuss with your counselor if you have any questions. 


Professional Boundaries

We refrain from having a relationship with any of our clients outside of sessions. For a healthy therapeutic relationship, we avoid any social or business relationships for better outcome, including social media, of counseling. 



- Daytime and evening appointments are available. You are responsible for coming to your session on time. Sessions usually last for 50 minutes. Appointments can be set up via email. If you are late to the appointment, your session will have to end as scheduled originally. 

- For emergencies, please contact your local authorities or medical institutions. For police, please call 110.

- Cancellation and/or rescheduling of your appointment can be made for free until 5 pm on the business day prior to your appointment. (If your appointment is on Monday, you are asked to contact us by the former Saturday, as long as our office is open on Saturday. If Saturday is holiday, you are asked to contact us by the former working day.) However, if you contact us after 5pm a day prior to your appointment, the full session (100%) fee for the scheduled session will be charged to you.  

- If you miss your appointment without notifying us by 5pm a day prior to your appointment, cancellation will be charged at the full scheduled session fee. Please check with your counselor for exceptions. 

- Cancellation and no show fees need to be paid promptly. This fee must be paid before or at the time of your next appointment to continue your counseling relationship with your counselor.

- In case your counselor has to cancel your sessions with you for emergency reasons, etc, we will do our best to notify you as soon as possible. 

- Due to the nature of the work of counseling, we do not accept refunds for services rendered. If you had an issue with the service rendered, please discuss this with your counselor. 

- In case of inclement weather, a challenge with transportation, medical emergencies and other extreme conditions beyond your control, you are not subject to the cancellation fee. 


Termination of Counseling sessions: 

Our goal is to assist you in obtaining your desired therapeutic outcomes. If you have any questions or concerns about any aspect of counseling, please discuss them with your counselor. If you elect to terminate or suspend treatment, it is a good idea to plan for your termination in collaboration with your counselor because it may allow you to bring sufficient closure to your work together with your counselor. 

You may discontinue your counseling session at any time. If you or your counselor determines that you are not benefiting from treatment, either of you may elect to initiate a discussion of your alternatives (e.g. referral, changing your goals or termination of therapeutic relationship.)


  • Fees are based on session time.

  • The fees for a 50 min. individual session is 10,000 yen plus 10% consumption tax, which is 11,000 yen, and a 80 min individual session is 15,000 yen plus 10% consumption tax, which is 16,500 yen.  

  • The fee for a 50 min. couples or family session is 15,000 yen plus 10% consumption tax, which is 16,500 yen, and a 80 min session is 22,500 yen plus 10 % consumption tax, which is 24,750 yen.

  • The first session fee is non-negotiable. 

  • The fee for a family session depends on a counselor and on the number of participants to a session. Please check with your counselor. 

  • The sliding fee scale may be used to determine the fee for lower income clients depending on a counselor. The condition for a lower fee depends on each counselor or the circumstances of the counselor at that time. Some counselors do not have lower fee scale. 



We keep brief records, noting only that you have been here, and the topics we discussed. We maintain your records in a secure location. The information will be discarded five years after your last visit. The documentation shall include: (1) client name(s), date of birth, address, phone number, email address, family members, (2) dates counseling was received, (3)  disclosure form, (4) the presenting problem and diagnosis if there is any, (5) information obtained from other persons or agencies through a release of information, (6) progress notes



If you have a complaint about our services, please do not hesitate to contact our Director, Mr. Eito Kusakabe by email. You are welcome to write to . We appreciate your feedback for us to be able to grow or change for the better. 

This statement could be updated, and your counselor will let you know about changes.


By signing below, I confirm that I have read, understood and agreed to the content of this document.

If you have any questions or concerns, please contact us at

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