Client Intake Information and Consent Form
UPDATED DEC, 13, 2023
ACCOUNT INFORMATION AND CONSENT FORM
Thank you for your interest in our services.
Inlined with MindWell by CML Well-Being and Psychological Services, gathering of essential information such as your medical records including but not limited to, your age, residence, past medical history, results of medical examinations, diagnosis, abstracts, treatments, health maintenance organization (HMO) are required by your mental health professional needed for screening for your session.
Your trust and confidence are vital to us. All the information gathered in this form will be treated with the utmost confidentiality. To ensure that CML Well-being and Psychological Services remains a trustworthy partner in your journey towards well-being, we make every effort to comply fully with the existing laws and regulations that govern us.
All of the data provided to us and/or collected by us will be used and processed by appropriate personnel, subcontractors, and medical facilities connected with us, including, but not limited to, its doctors, nurses, consultants, and we may disclose such information to our agents and affiliates, including your employer and the government, whenever permitted or necessary under Republic Act No. 11332, also known as the Law on Reporting Communicable Diseases.
Kindly read through the terms and conditions for your acceptance.
TERMS AND CONDITIONS:
In compliance with the Data Privacy Act (DPA) of 2012, you understand and agree that by providing your personal data, you are agreeing and giving your full consent to CML Well-being and Psychological Services to collect, store, access, and/or process any personal data you may provide herein, such as but not limited to your name, mobile number and email address, whether manually or electronically, for the period allowed under the applicable law and regulations, and solely for the purposes of your services requested from CML. You acknowledge that the collection and processing of your personal data are necessary for such purposes. You are aware of your right to be informed, to access, to object, to delete or omit or stop, to damages, to file a complaint, to rectify and to data portability, and you understand that there are procedures, conditions, and exceptions to be complied with in order to exercise or invoke such rights. All such information shall be purged from our records after the closure of your counseling services/engagement with us as prescribed by law.
By using this form, you accept the responsibility for and agree on the following:
Supplying, checking, and verifying the accuracy and correctness of the information provided on this system in connection with your registration, and consent to the collection and use of your personal information.
Following each evaluation, we will compile reports based on the data gathered. Your Information will be retained by us for this purpose for at least 5 years from the date of creation or 5 years of the last effective date of record entry whichever is later, subject to your rights to reasonable access to, and correction of, your Information upon demand, as well as your right to file a complaint with the National Privacy Commission. We will protect your information in compliance with our privacy policies, and the policies of your employer.
You understand that when you have an urgent need for counseling, you are most welcome to contact our affiliated crisis line numbers at +63 2 8893 7603 or 0917 800 1123 or 0922 893 8944 should you not be able to schedule with our helpline.
All schedule availability and confirmations are subject on a first-come, first-served basis. Payment for the session or approved LOA is considered as confirmed session.
You are advised to be online 5 minutes prior to your scheduled online appointment and at least 15 minutes for face-to-face session.
You are allowed to cancel or postpone your schedule at least 24 hours before the scheduled appointment. If the cancellation was made less than 24 hours will be subject for approval depending on the validity of the event by the management of MindWell by CML Well-Being and Psychological Services.
Cancellation and rescheduling beyond 24 hours is available at no charge, rescheduling is accepted no later than 4 hours prior to the scheduled session.
Rescheduling within 4 hours or less will incur an additional 25% rescheduling/administrative fee, and is subject to the availability of the professional.
Cancellations or Failure to attend a scheduled session without prior cancellation notice constitutes a "No-Show" and will be charged a 100% charge of the fee.
With the foreseen cancellation of the schedule, you may receive notifications for earlier available slots through chat, SMS, or email, using the contact details you provided.
Sessions extended beyond 15 minutes will be considered as an additional session, and will billed to you..
INFORMED CONSENT:
This information form includes your informed consent, highlighting the following:
You certify that you have freely appeared for mental health consultation and as applicable, for coaching/consultation, counseling/guidance/therapy session at the date and time scheduled, which you personally or a person you authorized arranged or was made known, and which you concurred. Also, you agree that your mental health professional may determine that due to certain circumstances, telepsychology could at any point of your session/s be no longer appropriate and you agree to resume sessions in person.
You have likewise been assured that the results of the interview, presenting issues, and all other information including but not limited to test results, if any, shall be kept confidential and shall not be disclosed to anyone without your consent and approval in writing.
You agree to the use of technology for the session/s. This is a HIPAA-compliant platform that uses video and audio technology through a webcam on your device and our device to connect us securely. You understand that you are solely responsible for maintaining the strict confidentiality of your user ID and password and not allowing another person to use your user ID to access the services. You also understand that you are responsible for using this technology in a secure and private location so that others cannot hear your conversation. Furthermore, you understand that you are not allowed to do any recording, screenshots, etc. of any kind, of any session, and are grounds for termination of the client-coach/counselor/therapist relationship.
Through this form, the information gathered, assessment results, the purpose, duration, and specific instructions were clearly stated to you and you understand that MindWell, as your service provider, will determine on an ongoing basis whether the condition being assessed and/or treated is appropriate for an online session.
You also understand that a comprehensive medical face-to-face evaluation by a physician/professional/specialist is not meant to be replaced by online consultation.
As a result, you will be given a limited and preliminary diagnosis.
You understand and agree that upon registration, you will participate in the planning for your care, treatment, or services and that you may withdraw consent for such care, treatment, or services at any time.
You understand and agree that if you wish to have a copy of your records upon approval with the Mindwell by CML management for your reference, this will be through the email you will provide in the form.
Finally, you agree to assure and hold the Company, its officers, directors, stockholders, employees, consultants, and/or doctors/professionals/specialist harmless from all claims, suits, charges, fees, damages, or liabilities arising from or related to (a) your legitimate use of the service, (b) the collection, processing, release, or disclosure of your information, including, but not limited to, your medical records; provided that the processing of your Information is done under the terms of this Agreement.
I acknowledge that by clicking the "I Accept Terms and Conditions" button to proceed to the next page I have confirmed my acceptance and consent to continue with my session/s. By clicking the "Start Survey" button in this Informed Consent and submitting this form, I acknowledge that I have both read and understood all the terms and information contained herein, and ample opportunity has been offered to me to ask questions and seek clarification of anything unclear.
*Please be informed that when you choose not to click the "I Accept Terms and Conditions" button or decide not to continue, the process will stop and you won't be able to proceed. We encourage you to contact our well-being and psychological services director at [email protected] for further clarification or assistance you may need.*