Clinical Interview and Consent Form

Client information and consent form

This form aims to facilitate a more convenient experience for you as you undergo psychological assessment with us at MindWell.  Carefully review all fields and provide complete and accurate information.
 
Your trust and confidence is important to us. All the information gathered in this form will be treated with utmost confidentiality.  As a trusted partner, we ensure to extend this in your journey with us and we make every effort to fully comply with the existing laws and regulations that govern us.
 
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 erasure or blocking, 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 services/engagement with us as prescribed by law. 

By using this form, you accept the responsibility for and agree on the following:
  1. 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. 
  2. Should there be at any point you have a need for psychological support after our session, you are most welcomed to contact and schedule for our psychological support at http://m.me/mindwellph.
  3. You are only allowed to postpone your schedule at least 3 days before the scheduled appointment. 
  4. With the foreseen cancellation of the schedule, You agree that you may receive notification of earlier available slots for an appointment schedule through SMS, chat, or email, subject for your confirmation.  This schedule is again subjected on a first come, first served basis.
  5. All schedule confirmation are subjected on a first-come, first-served basis.

INFORMED CONSENT:  This consent  form includes your agreement, highlighting the following:

  1. You certify that I have freely appeared to undergo psychological evaluation and as necessary and applicable, mental health consultation and therapeutics, at the date and time scheduled, which you personally arranged or was made known to, 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.  
  2. You have likewise been assured that the results of the interview, presenting issues, 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.
  3. You agree to the use of technology for the session/s. You understand that any problems with internet availability or connectivity are outside our control and thus, we can not make any guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment/s due to technical complications and the session cannot be completed via online video, you agree that we will either use the in-session video chat to troubleshoot or will call you back through a different platform to complete the session. This is to be done through a HIPAA compliant platform that uses video and audio technology through a webcam on my device and my device to connect us securely. You understand that I am solely responsible for maintaining the strict confidentiality of my user ID and password and not allow another person to use my 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 my 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 this procedure.
  4. 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 on-going basis whether the condition of the process, being assessed and/or treated, is appropriate for an online session.  
  5. You understand and agree that upon registration, you will participate in the planning for your diagnosis, care, treatment, or other services and that you may withdraw consent for such care, treatment, or services at any time.
  6. You agree that the professional may determine that due to certain circumstances, your option to undergo this psychological evaluation could at any point of the session/s be no longer appropriate and you agree to resume session/s in-person.
  7. The duration of the session may last for about 1 to 3 hours. The length of psychological interview and the timing of the eventual termination of procedure will depend on the completion of a series of psychological tests and clinical interviews will depend upon the questions or validating / follow through inquiries you or the mental health professional may have.
  8. You have the access to evidence-based and standardized assessments as well as certified and/or licensed mental health professionals who will provide up to date protocols and modalities free from discrimination based on socioeconomic status, race, ethnicity, or sexual orientation.
  9. When completing forms and/or online examination, you understand that you may not use textbooks, course notes, or receive any help from another source during the examination or session and may not stop and return to it if not finished with the session.
  10. If you are a minor client, this form confirms you consent to disclose to your identified guardian the results of the assessments and use this for consideration in supporting your mental health and overall welfare.
  11. You have been assured that the results of the interview, presenting issues, all other information including but not limited to test results, if any, shall be kept confidential and shall be disclosed to anyone without your consent and approval in writing. However, you understand that CML will be required to disclose by law or for research educational purposes where your identity will NOT be specified nor disclosed, in a life threatening emergency or an impending danger to self or others, is being abused, or unable to care for themselves, or other legal circumstances.
Kindly click "I Accept Terms and Condition " button to indicate your acceptance and consent, confirming you acknowledged the terms and conditions of your session/s.  By clicking the "Start Survey" button in this Informed Consent and submitting this form, you acknowledge that you have both read and understood all the terms and information contained herein, and ample opportunity has been offered to you to ask questions and seek clarification of anything unclear to you.

Please be informed that when you choose not to click the "I Agree Terms and Condition" button, you won't be able to proceed with the process and are encouraged to contact our well-being and psychological services director at [email protected] for further clarification or assistance you may need.





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