Appointment Schedule for Evaluation/Assessment

REGISTRATION FORM

Good day! We are third-year Occupational Therapy students for Academic Year 2025-2026. As part of our first-semester activity, we are seeking individuals to participate in our Teleconsultation. If you're reading this, we believe you may be interested in participating as a client and are ready to register. To do so, please click the next.

In adheranceto to the "Data Privacy Act of 2012", we the Third Year Occupational Therapist Students, believe that data privacy is an essential component of ethical practice. We:
1. By registering to this service, you are permitting the Occupational Therapy students to collect any data that is relevant to the administration of services,
2. Will only collect the minimum amount of personal data necessary to provide services
3. Will keep all personal data confidential and secure. We ensure that our clients' personal data is only accessible to authorized personnel and is protected against unauthorized access, use, or disclosure.
4. Will obtain informed consent from our clients before sharing any personal data with third parties, except where required by law or with the client's explicit consent.
Will respect our clients' right to access, correct, and delete their personal data. We also ensure that our clients are aware of their rights in relation to their personal data and how to exercise them.
5. Will review and update our data privacy policies and procedures on a regular basis to ensure that they remain current and effective.
6. By following these ethical guidelines, we strive to ensure that our free Occupational Therapy consultation is conducted in a manner that is respectful, transparent, and aligned with ethical principles.

Registration Form: Readiness and Willingness to Adhere

In this section, we look forward to the enthusiasm of the selected clients who will participate in our free teleconsultation. This is a "first come, first serve" basis service and there are only Nine (9) slots available (3 for Pediatric Conditions, 3 for Physical Dysfunctions, and 3 for Psychiatric Conditions). Late registrees (Individuals who cannot take advantage of the slots given) will be automatically included as reservees for the teleconsultation.
Dinhi na bahin, kami maukyabon sa kadasig sa among mga partisipante sa pag apil sa atong libreng Teleconsultation. Kini na serbisyo kay "first come, first serve" ug aduna lamang pito (9) ka slot na pwede na mo mahatag (3 sa Pediatric Conditions, 3 sa Physical Dysfunctions, ug 3 sa Psychiatric Conditions). Ang mga indibidwal na maiwit ug register kay dayon iapil sa reserve list para sa teleconsultation.
I will make myself available on the following dates to be given for my consultation (Ako makahigayon ug paghatag sa akong oras sa mga adlaw na diin ako iskedyul):
I will forfeit my slot to the next participant if I am not able to reply to the confirmation message for the Teleconsultation. (Akoang ihatag ang akong slot ug dili ako maka kumpirma sa akonog pag partisipar sa sulod sa 24-oras)
I am well-versed in using virtual meeting applications or I have someone to assist me (Sweto ako sa pag gamit sa mga virtual meeting applications o Aduna ako'y kabanay na makatabang sa akoa)

Registration Form: Personal Information
Client's Full Name

First NameLast Name
Gender
Client's Birthdate

MonthDayYear
Date
Parent/Guardian's Full Name

First NameLast Name
Parent/Guardian's Contact Number
Client's Email
example@example.com
Current Address

Registration Form: Awareness to Condition

In this section we will ask for the particpant's awareness to their condition. This will help us in constructing our Psychoeducation and Home Instruction Program (H.I.P.).
Dinhi na bahin, kami naga pangutana sa kahibalo sa partisipante matod sa iyang kondisyon. Kini makatabang sa among pag himo sa among Psychoeducation ug Home Instruction Program (H.I.P.)
I am aware of my condition (Ako nakamatikod sa akong kondisyon)
My family and friends are aware of my condition (Akong mga kapamilya ug kabanay nakamatikod sa akong kondisyon)
What is your clinical diagnosis? If undiagnosed please put "N/A" (Unsa ang imong kondisyon? ug wala ka pa ma diagnose palihog ibutang ang "N/A")
I have been medically diagnosed by a licensed physician (Ako gi - diagnose sa usa ka lisensyado na doktor)
I have a support group that can help me in doing my daily occupations (Aduna akoy mga kapamilya ug kabanay na maka tabang sa akong pang adlaw adlaw na himuonon)

Please Select an Appointment Date and Time Between October 19 - November 9 ONLY
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