Client Intake Information and Consent Form
MindWell Philippines Inc.
Account Information and Informed Consent Form
Updated October 10, 2024
Thank you for choosing MindWell Philippines Inc. for your mental health and well-being needs. To provide you with high-quality services, we collect, process, and store essential information about your medical and personal history. This form outlines the terms under which we gather, use, and protect your information, as well as your rights under applicable laws, including the Data Privacy Act of 2012 (Republic Act No. 10173).
Your trust is paramount to us. All personal information shared with us is treated with the utmost confidentiality. Please review this document carefully to ensure your informed consent before proceeding with your consultation or services.
I. Information Collection and Usage
We will collect and process your personal and medical data, which may include but is not limited to the following:
Full name, age, residence, contact details
Medical history, diagnoses, abstracts, treatment plans
Results of medical examinations, mental health assessments
Health Maintenance Organization (HMO) details
This information is essential for your mental health professional to accurately screen, diagnose, and plan your sessions and treatments. Data may be collected manually or electronically and processed by authorized personnel, consultants, subcontractors, and affiliated medical professionals.
Your data may be shared with third parties such as your employer, insurance provider, or government authorities as permitted by law, particularly under the Law on Reporting Communicable Diseases (Republic Act No. 11332).
II. Trauma-Informed Decisions
MindWell recognizes the potential impact of trauma on mental health. In light of this:
Understanding Trauma History: We acknowledge any trauma history you disclose, and we ensure a consent process that is sensitive and supportive.
Empowerment: We provide you with comprehensive information about your rights and options, empowering you to make informed decisions.
Collaboration: We work with you to develop a treatment plan that aligns with your needs and goals.
III. Diversity, Equity, and Inclusion (DEI)
We value cultural sensitivity and inclusivity in our services:
Cultural Sensitivity: We respect cultural differences, ensuring the consent process reflects your beliefs and values.
Language Accessibility: Consent forms and information are provided in languages that you understand.
Inclusive Environment: We strive to create a welcoming space where you feel comfortable discussing your concerns.
IV. Data Privacy and Confidentiality
MindWell strictly complies with the Data Privacy Act of 2012 and ensures that:
Your personal data will only be used for the purposes stated in this consent.
Your data will be stored and processed for the duration necessary to fulfill the purpose of your services and will be purged from our records as per legal requirements.
All information is kept confidential and will not be disclosed without your written consent, unless mandated by law.
Clear Expectations: We communicate clearly the limits of confidentiality (e.g., risk of harm to self or others) and the circumstances under which your information may be shared.
Privacy Measures: Robust systems are in place to protect your privacy, including secure electronic records and physical document storage.
V. Client Rights
As a data subject, you are entitled to the following rights:
Right to be Informed: You have the right to know how your data is being processed and used.
Right to Access: You may request access to your data at any time.
Right to Rectification: You may correct or update your personal data.
Right to Object: You can refuse data processing in certain circumstances.
Right to Erasure: You may request the deletion of your data upon the completion of your services, subject to legal conditions.
Right to Damages: You have the right to claim damages due to unlawful processing of your data.
You may exercise these rights by contacting us directly at [email protected] or the National Privacy Commission.
VI. Informed Consent for Services
By providing your consent, you agree to participate in the following services offered by MindWell:
Psychological Assessments: Includes tests and evaluations to assess your mental and emotional state, helping guide treatment plans.
Psychotherapy: Ongoing sessions with a mental health professional to address psychological concerns and guide you toward emotional well-being.
Family Therapy: Sessions with family members to improve communication and resolve conflicts, aimed at enhancing family dynamics.
You also acknowledge that MindWell may determine whether teleconsultation services are appropriate for you and that in-person sessions may be recommended if deemed necessary.
VII. Teleconsultation and Use of Technology
MindWell offers HIPAA-compliant teleconsultation services through secure video and audio platforms. By agreeing to use this technology, you understand that:
You are responsible for maintaining the confidentiality of your user ID and password.
Sessions must be conducted in a secure and private environment.
Recording or taking screenshots of any session is strictly prohibited, and violations will result in the termination of services.
MindWell professionals will determine the suitability of teleconsultation services on a case-by-case basis.
VIII. Session Scheduling and Cancellation Policy
Booking: Sessions are confirmed upon payment or submission of an approved HMO - LOA (Letter of Authority).
Cancellations: Appointments must be cancelled at least 24 hours in advance. Cancellations made less than 24 hours before a session may be subject to approval, depending on the circumstances.
Rescheduling: Appointments may be rescheduled free of charge if done 4 hours before the session. A 25% rescheduling fee will apply if rescheduled within 4 hours of the appointment.
No-Shows: Failure to attend a session without prior cancellation notice will result in a 100% charge of the session fee.
IX. Crisis Intervention and Ethical Considerations
We have protocols for addressing crises or emergencies. MindWell adheres to ethical guidelines and standards to ensure the best care for you.
X. Duration and Retention of Information
MindWell will retain your personal data for at least 5 years from the date of the last session or record entry, whichever is later. After the completion of your services, your data will be securely archived and disposed of following applicable regulations.
XI. Liability Waiver
By agreeing to these terms, you:
Acknowledge that you are participating in voluntary mental health services and that MindWell's professionals will act within the scope of their expertise.
Agree to hold MindWell, its employees, and affiliates harmless from claims, damages, or liabilities arising from the legitimate use of its services and the processing of your personal data as described in this form.
XII. Additional Consent
In specific cases or situations, additional consent may be required based on your treatment needs, legal requirements, or service agreements. This may include consent for sharing information with third-party providers or entities based on the terms of your service.
XIII. Specific to Company-Sponsored Services
If your services are sponsored by a company, the following additional considerations apply:
Employee Rights: Your rights regarding confidentiality are upheld.
Workplace Privacy: Your mental health data is protected within the workplace setting.
Company Policies: Informed consent practices align with the company’s policies.
XIV. Acknowledgment and Acceptance
By clicking "I Accept Terms and Conditions," you acknowledge that you:
Have read and understood the terms outlined in this consent form.
Have been given the opportunity to ask questions and seek clarifications.
Provide your informed consent for MindWell to collect, process, and use your personal and medical information for the purposes of the services you will receive.
If you do not wish to proceed, please contact us at [email protected] for assistance or clarification.
Thank you for choosing MindWell. We are committed to supporting your mental health and well-being in the most professional and confidential manner possible.
MindWell Philippines Inc.
Contact: [email protected]
Helpline: +63 2 8893 7603 | 0917 800 1123 | 0922 893 8944