Therapy Informed Consent Form

Welcome! This is a therapy practice deeply committed to confidentiality, multicultural sensitivity, and quality care. It is our intent to provide quality-counseling services combined with systemic, cognitive, and solution-focused approaches. It is our hope that the issues that have brought you into therapy may be resolved as we work together.

In accordance with the Mental health Act of 2017 (RA 11036) and Data Privacy Act of 2012, the following Professional Disclosure Statement is provided for the client and must be signed by both the client(s) and the mental health professional (Psychologist, Counselor, Psychometrician and Intern). The client’s signature indicates that she/he has read and understands the information.

Provider Information

Telehealth or Telemental health psychologists, counselors, psychometricians, interns, and psychotherapists are from diverse educational background with a varied set of clinical experiences in mental health, psychology, family therapy, and addiction services. Psychologists in training or Clinical interns are working on getting their required training and experience in the mental health and addiction field. Licensed Mental Health Professionals who work in our Telemental health clinic are Marriage & Family Therapists, Mental Health Counselors, Master Addiction Counselors, Psychometricians, and Psychologists who have, at minimum, a Master’s degree and/or Doctoral degree in Psychology except for the Psychometricians, they have at least a Bachelor degree. They are licensed by the Professional Regulatory Commission (PRC) and considered independent behavioral/mental health practitioners. Clinical interns and psychometricians are under the supervision of a licensed Psychologist. They are not allowed to prescribe psychotropic medications but could refer you to a medical prescriber (Psychiatrist) while receiving psychotherapy from our virtual facility.

Length of Sessions:

Pro-bono is limited to 6 sessions and a maximum of 12 sessions after authorization from the clinical supervisor/director or administrator.  

Individual Therapy - 6 sessions. This may be extended to another six sessions.

Peer & Emotional Support 6 sessions. This may be extended to another six sessions.

Wellness Group - One-time seven weeks group sessions

Counseling Contract of Services: You must sign our pro-bono policy and this informed consent.

Financial Requirements:

This is a pro-bono service.

Our Payment Center: If you need to pay for other services. 

MHFR Website Link: https://www.mhfirstresponse.org/telehealth-payment-portal.html 

MHFR App: You are already using it. Please, select the desired services below after signing this informed consent.

Late Policy

If you are late, your session will still end at the scheduled time. Please remember that individual, couples, and marital therapy is a 53-55-minute session. Being 15 minutes late will result in last-minute cancellation of your pro-bono services.

Verification Letter

Letters to institutions, companies, work, schools, courts, military, and other third parties for the purpose of verifying your participation in counseling, as well as other letters that we have to write on your behalf, will be billed separately. A separate letter containing treatment summaries and diagnostic impressions which require more than 30 minutes of billable time will be billed at a flat rate of Php 500.00.  A simple form letter for attendance verification is available upon request.

Cancellation/No Show/Missed Appointments: Missed appointments are NOT free. Since scheduling an appointment involves reserving time specifically for you, a minimum of 48 business hours' notice is required for cancellation. Sessions that are last-minute cancellations missed or no-shows without this advanced notice will incur a penalty. Appointments canceled with less than 48 business hours' notice will be considered last-minute cancelations. If you have multiple cancelations, we may require proof of the reason.  After 2 missed appointments, we will then close your case.

Additional Charges

Request for Records: We will provide and release your records with a signed release of information. A small per-page printing charge will be assessed to print your records for your personal use or provide them to third parties. Other financial considerations may arise in the counseling/therapy experience.

Disability or Other Paperwork: Completion of forms such as the DSW, disability paperwork, or any other paperwork directly related to your care needs to be discussed first with your psychologist or therapist. The paperwork completion will take place at your individual time with your assigned psychologist. We also charge you if we have to provide testimony or disposition in relation to any court or legal matters.

Confidentiality 

Your participation in counseling, the content of your sessions, and any information you provide to your provider during those sessions are protected by legal confidentiality. Exceptions to confidentiality occur in the following situations where your provider may choose to, or be required to, disclose that information:

• If you give written consent to have the information released to another party;
• In the case of your death or disability, your information may be disclosed to your personal representative
• If you waive confidentiality by bringing legal action against your provider
• In response to a valid subpoena from a court or from the PRC for records related to a complaint, report, or investigation
• If your provider reasonably believes that disclosure of confidential information will avoid or minimize an imminent danger to your health or safety or the health or safety of any other person
• If, without prior written agreement, no payment for services has been received after 30 days, the account name and amount may be submitted to a collection agency
• If the contemplation or commission of a crime or other harmful act is revealed
• If your provider has any other legal right or obligation to report

As a mandated reporter, your provider must disclose certain confidential information, including suspected abuse or neglect of children under Philippine laws.

Social Media Policy 

Professional ethics standards do not permit healthcare providers to communicate with clients via personal social media. Texting that is part of the MHFR Telehealth Services Program platform is secured and HIPAA compliant. Our Telehealth platform is also HIPAA compliant in order to protect your privacy and confidentiality.

Emergencies 

If you are experiencing an emergency or crisis, please call 911, the NCMH Crisis line at 0917-899-USAP (8727), In Touch Philippines Call Crisis Line, any time +63 2  893 7603 (Landline)
+63 917 800 1123 (Globe), +63 922 893 8944  (Sun). You may also go to the nearest hospital emergency room. Crisis or mental health emergencies should be directed to the local crisis line or by dialing 911.

Telehealth or Telemental Health:

I hereby consent to engage in the Telemental health program at MHFR Telemental Health Services as part of my psychotherapy and online counseling. I understand that “Telehealth/Telemental Health” includes the practice of health care delivery, assessment, diagnosis, consultation, treatment, transfer of medical data, texting, and psychoeducation using interactive audio, video, or data communications. I understand that, with my signed consent, telehealth and mental health program may also involve the communication of my mental health information by texting, orally and visually, to other health care practitioners licensed in the Philippines.

Technology: I understand that I will need to use and log into the Doxy.me app, Gmeet, Zoom, etc. in order to use this platform. I also need to have a DSL/Broadband/Fiber Internet connection or a smart phone device with a good cellular connection at home or at the location deemed appropriate for services. I also understand that in case of technology failure, I may need to test the platform ahead of time in order not to miss the appointment.

I understand that using the Telehealth or Telemental health platform allows access to mental health or psychological services that might not otherwise be available to me due to my mental health and/or my physical, resource, or geographic limitations due to traffic and distance. I will access and conduct the session with my provider in an area that protects my confidentiality.

Video/Audio Recording: As a general practice MHFR Telemental Health DOES NOT record Telehealth sessions without prior permission. I agree not to record in video or audio format nor divulge the details of my consultation in compliance with the Data Privacy Act of 2012.

Confidentiality: The laws that protect the confidentiality of my medical information also apply to telehealth and Telemental health program. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. MHFR Telemental health program platforms are HIPAA compliant to protect my privacy and confidentiality. This is further explained in the Mental Health Informed Consent above. 

I understand that I have the following rights concerning Mental Health, Telehealth and Psychological Testing Programs:

• I have the right to withdraw my consent at any time.
• I understand that there are risks and consequences associated with Telemental health including, but not limited to the possibility, despite reasonable efforts on the part of my counselor/therapist/clinical intern, that the transmission of my medical information could be disrupted or distorted by technical failures. In addition, I understand that Telemental health-based services and care may not be as complete as face-to-face services. I also understand that if my psychologist/therapist/clinical intern believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a psychologist/therapist who can provide such services in my geographic area.
• I understand that I may benefit from telehealth and/or Telemental health program, but that results cannot be guaranteed or assured.
• I understand that I have a right to access my mental health information and copies of medical records in accordance with the mental health law in the Philippines.

I have read and understand the information provided above. I will discuss it with my psychologist, counselor, therapist, psychometrician, and clinical intern if I have any other questions. My signature below indicates my informed and willful consent to treatment using this platform. 

Questions or Concerns

If you have any questions concerning the therapy and its progress, or if you're getting unhappy with the therapy progress, please let us know immediately so we can address your concerns as soon as possible. Your criticisms and views are important to us. Feel free to contact us through this What's App phone number via text: +1-360-292-9044.

Consent for Treatment, Financial Responsibility, and Release of Information

By signing this document, you attest that you have received, read, fully understand and consent to the disclosures, terms, and conditions above in the Individual Provider information and have been allowed to ask questions. By signing this document, you also consent to participate in services provided by the MHFR provider named below.

I agree to be responsible for canceled appointments in accordance with the MHFR Telemental Health Services cancellation policy, as documented by my signature on this Informed Consent. 

This policy is effective January 1, 2023, and supersedes all previous informed consent and/or MHFR Telemental Health Services policies.

By signing this informed consent and in my capacity as a therapist:

1. I affirm that I have fully explained the information here in this informed consent to the client/patient and by which the information shared was well understood by the said client/patient;

2. I have given the client/patient the opportunity to ask questions and all of which were answered to the best of my knowledge and to the satisfaction of the client/patient's understanding