(Applicable to Onsite and Online Services)

If or when I avail of onsite and/or online counseling, psychotherapy, and/or psychological assessment services with Psychwell Companion Psychological Services, I understand that these services shall be subject to the conditions provided herein below:

Psychwell Companion Psychological Services provides the following professional services, which may be conducted onsite or online, depending on the nature of the service and professional judgment:

a. Counseling and Psychotherapy – ongoing therapeutic services aimed at emotional, psychological, and behavioral concerns;

b. Psychological Assessment – the use of standardized tests, interviews, observations, and other assessment tools for clinical, educational, or work-related purposes.

I understand that counseling/psychotherapy and psychological assessment are distinct services, with different purposes, processes, and outcomes.

All matters discussed and all data obtained during counseling, psychotherapy, or psychological assessment—whether conducted onsite or online—shall be treated as strictly confidential. No party may record (audio and/or video) any session, assessment, or testing process.

Information disclosed may only be released with my written permission, except in the following cases, in accordance with applicable laws and regulations:

a. If the psychologist determines a risk of self-harm;
b. If the psychologist determines a risk of harm to others;
c. If the psychologist is informed about or suspects abuse, neglect, or exploitation of a minor or an incapacitated adult; or
d. If the psychologist believes that a person's mental condition leaves them gravely disabled.

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Personal data shall be processed in accordance with Republic Act No. 10173 (Data Privacy Act of 2012), its Implementing Rules and Regulations, and issuances of the National Privacy Commission.

For online services, I acknowledge that reasonable security measures are in place. However, I understand that online communication involves inherent risks, and I am responsible for ensuring privacy on my end (private space, secure internet connection, personal device).

I understand that:

• Counseling and psychotherapy may involve emotional discomfort as sensitive topics are discussed;
• Not all concerns can be resolved within a limited number of sessions;
• Treatment plans may be adjusted depending on progress, circumstances, and modality (onsite or online).

I understand that:

1. Psychological assessment involves the administration, scoring, and interpretation of psychological tests and related procedures;
2. Assessment results are based on the information available at the time of evaluation and are not absolute or permanent descriptions of my abilities, personality, or mental health;
3. The accuracy and validity of results depend on my cooperation, honesty, effort, and current condition during the assessment;
4. Assessment results are intended only for the specific purpose agreed upon and may not be applicable for other purposes without re-evaluation.

A psychological assessment report may be released only after full payment and completion of all required assessment procedures.

Feedback regarding results may be provided through a feedback session when applicable.

Assessment reports are issued for the stated purpose only (e.g., clinical, educational, employment-related) and shall not be used for legal or court-related purposes.

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Sessions and assessment appointments typically last sixty (60) minutes, unless otherwise specified. All appointments must be scheduled at least twenty-four (24) hours in advance.

• Payments must be made within twenty-four (24) hours from booking.
• A grace period of fifteen (15) minutes applies.
• A minimum of twenty-four (24) hours' notice is required for cancellations.
• Rescheduling is allowed within one (1) month from the original appointment date; otherwise, fees are forfeited.
• Late cancellations or no-shows are charged 100% of the appointment cost.

Session certifications may be requested for a corresponding fee. Certifications are issued for personal or work-related documentation purposes only and shall not be used for legal, judicial, or court-related purposes.

Certification requests must be made within one (1) month from the date of the appointment.

I agree to comply with the safety plan provided by my psychologist. I consent to the activation of my emergency contact when deemed necessary.

For online services, I agree to provide accurate emergency contact information and disclose my current location when requested for safety reasons.

I acknowledge that I have been informed of the nature, purpose, risks, and limitations of counseling, psychotherapy, and psychological assessment services. All my questions regarding this agreement have been answered.

By affixing my name and the date below, I confirm that I have read, understood, and voluntarily agreed to the terms and conditions stated herein.

Aileen Rose T. Jimenez, MA, RPsy License No. 483

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