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Making an appointment

Sky Counseling & Consultation Tokyo

counseling consent form


Thank you for choosing Sky Counseling & Consultation Tokyo (hereinafter referred to as our center). This document is for the purpose of conducting counseling after obtaining the understanding and consent of everyone before counseling. Please fill in the signature date at the end. If you are booking as a couple or family, please ensure that all guests sign and date.

Counselor Qualifications

Sky Counseling & Consultation Tokyo counselors have different qualifications. If you have any questions about eligibility, please contact each counselor directly.

counseling service

  • The center provides counseling services to support children, adolescents, adults, couples and families with a wide range of mental health challenges and issues. Target age varies by counselor.

  • Counseling provided at the center is not a medical practice.

  • If you are going to a medical institution such as internal medicine, psychiatry, etc., please make a reservation after obtaining permission from the doctor.

  • If it is determined that a visit to a medical institution is necessary (eg, a life-threatening act is observed, etc.), we may recommend that you visit a medical institution.

  • - does not provide answers or give advice to clients' problems. We support our clients in making choices that best suit them, backed by our specialized knowledge and training.

  • Our goal is to improve your problems and situations. Examples of improvements include less depression and anxiety, improved relationships, and greater self-awareness.

  • It is set jointly by you and your counselor and can be modified as needed. We provide a safe and supportive environment to help our clients achieve their goals.

  • depends on the If you have any questions, please contact your counselor.


policy of non-discrimination

  • We do not consider any of our clients to be of culture, race, color, national origin, gender, sexuality, gender identity, age, religion, marital status, social standing, physical or mental disability. We value our policy that no one should be discriminated against based on their presence or absence.

  • informed consent

  • Counseling is one of the options that people choose to make changes in their lives and lives. Counseling has benefits, but it also has risks. Counseling often touches on areas of your life that you don't feel comfortable with or that you don't want to face. It can also lead to feelings of discomfort, sadness, guilt, anger, frustration, loneliness, and helplessness. Counseling on the one hand

  • may experience better relationships, improved self-esteem, or reduced negative emotions and stress.

  • Counseling period varies depending on the content of your consultation and symptoms. Counseling can be interrupted in the middle. In that case, it may lead to worsening of symptoms or recurrence, so if you are discontinued or dissatisfied, please tell the counselor directly. This process itself can sometimes have important implications for growth and healing. If you find it difficult to talk to a counselor directly, please contact the representative at We can refer you to another counselor.


  • Client's personal information will be strictly protected unless there is written consent, except in the following cases.

  • When there is abuse or neglect of the elderly or people with disabilities.

  • ・When the counselor in charge determines that there is a fact or possibility of harm to others or a similar situation of high urgency.

  • If the counselor in charge deems it necessary (with personal information protected) 

  • - If you happen to meet a client outside (ex: supermarket, etc.), our center staff, including counselors, will not talk to the client. Protect confidentiality by not acting like you know someone.


Diagnosis and Prescription

  • Japanese law prohibits counselors from diagnosing or prescribing medication, and we recommend visiting a medical institution if necessary. We do not have a partner hospital, but please let us know if you need information on a medical institution.


About insurance

  • The service provided by our center is not a medical practice, so it is not covered by Japan's social medical insurance. If you have overseas insurance, please contact your own insurance company directly. If necessary, we will issue a receipt and a visitor's certificate in Japanese and English, so please check it before the first interview.


About remote counseling

  • For online counseling at the center, we use an online platform that meets the safety standards of US HIPAA (US law on privacy protection and security).

  • Please refrain from audio and video recording.

  • In the event that the patient's condition deteriorates and there is no choice but to suspend counseling, the counselor in charge will take measures such as switching to another online platform or switching to telephone counseling.

  • Please understand that there is a risk that confidentiality cannot be maintained when counseling using a public computer that is not encrypted or protected by a password (e.g. library, internet cafe, etc.).

  • Your computer or account may be infiltrated by a computer or Internet provider, and you may not be able to maintain confidentiality.

  • Pay close attention to people looking at your screen and overhearing your conversations.  

  • Please ensure that your computer, internet access, email and passwords are encrypted and secure before attending a session.  

  • Please make sure you understand what you have rights to.

  • If we judge that online counseling is not suitable for you, we may stop the online interview after giving you an explanation.



  • To maintain a healthy and more effective therapeutic relationship, counselors do not have personal, social or business relationships with clients outside of counseling, including social media.



  • Reservations can be made from 12:00 to 20:00. Reservations can be made over the phone, but we recommend sending an email for easy confirmation. Please note that even if you are late for your reservation, we will not be able to extend the normal time as there is a next reservation slot.

  • Call medical 119 and police 110.

  • For changes, please contact us by e-mail by 17:00 on the business day before the reservation. (If your reservation is for the day after a Sunday or public holiday, please contact us by 17:00 on the previous business day.) If there is no cancellation notice or if you contact us after 17:00 the day before, 100 % cancellation fee will apply. There are exceptions, so please check with your counselor.

  • In the event that we have to cancel the reservation urgently, we will contact you as soon as possible.

  • In the case of unforeseen circumstances such as weather and natural disasters, no cancellation fee will be charged.



  • 11,000 yen with tax, 15,000 yen for 80 minutes + 16,500 yen with 10% consumption tax, 20,000 yen for 120 minutes + 22,000 yen with 10% consumption tax. For couples/family sessions, 50 minutes is 15,000 yen + 10% consumption tax for 16,500 yen, 80 minutes is 22,500 yen + 10% consumption tax for 34,750 yen, and 120 minutes is 30,000 yen + 10% consumption tax for 33,000 yen. Family session costs may vary depending on the counselor and number of participants.

  • Prices may be reduced depending on your income. However, please understand that we may refuse depending on the policy and circumstances of each counselor.



  • The following items will be recorded during the counseling session. Records will be kept in a secure location for 5 years from the last client interview.

  • (1) Name, birthday, address, phone number, email address, family structure

  • (2) Schedule of counseling

  • (3) Consent form

  • (4) Consultation content and diagnosis (if applicable)

  • (5) Information and information disclosure agreements from others or other centers

  • (6) Brief content of counseling (topics discussed, etc.)


  • If you are unsatisfied with our services, please feel free to contact our representative, Mr. Kusakabe, by phone or email at any time. . We take everyone's opinions seriously and want to be a center that can grow.  



  • The contents of this agreement may change in the future. Any changes will be communicated to you by your counselor.



  • IF YOU HAVE READ, UNDERSTAND, AND AGREE TO ALL OF THE ABOVE AND WANT TO CONSULT, PLEASE INITIAL BELOW EACH PAGE AND DATE AND SIGN BELOW. (If you are a minor, please ask your guardian to also fill in your name and relationship.)

Please carefully check the price and the name of your counslor below. If it is different from what you agreed with, please email at before you submit your disclosure statement

If you don't agree with states above, please contact us at

Your inquiry has been sent.

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