Client Intake Form

Important: If you are experiencing a life-threatening emergency, please call 911 or go to the nearest emergency immediately. This form is not monitored 24/7.

Data Protection & Privacy Notice
Mellow Wellness is committed to safeguarding your personal and health-related information. All data submitted via this secure form is encrypted and stored in compliance with standard data protection regulations. This information is accessed only by authorized practitioners to ensure clinical safety and service excellence.

 

INFORMED CONSENT FOR PSYCHOLOGICAL SERVICES

1. INTRODUCTION This document is designed to inform you about the psychological services provided by Mellow Wellness (“MELLOW”), specifically regarding Telehealth (Virtual counseling), and to obtain your consent for psychotherapy. Please read it carefully.

2. NATURE OF SERVICES Psychological services are provided to assist you with personal growth and mental health concerns. Psychotherapy is a collaborative process. Success depends on your active participation and willingness to explore difficult topics.

3. VIRTUAL COUNSELING Mellow Wellness strongly recommends keeping your video on to facilitate the therapeutic alliance. You are responsible for ensuring a stable internet connection, functional equipment, and a private room. If technical issues interrupt the session, your therapist will attempt to reconnect; If a stable connection is not restored within 10 minutes, the Therapist will email you to reschedule the session. Please check your email if a disconnection occurs.

• Confidentiality: While HIPAA-compliant technology is used, no internet transmission is 100% secure. There is a risk that data could be intercepted. By signing this, you acknowledge this risk.
• Emergency Protocol: Since session is remote, you agree to provide your current physical address and an emergency contact person. In the event of a mental health crisis or emergency, therapist may need to contact local emergency services to ensure your safety.

4. CONFIDENTIALITY AND LIMITS All information disclosed in psychotherapy is confidential and will not be revealed to anyone without your written consent. However, there are legal exceptions where your psychotherapist is mandated to break confidentiality:

• If there is a risk of imminent harm to others or yourself (suicide/self-harm).
• Suspected abuse or neglect of children.
• If a court of law orders the release of records.

5. ATTENDANCE & DEPOSIT Individual therapy session are between 50 and 60 minutes in duration. Session frequency can vary over the psychotherapy period, depending on the specific therapy goal and the progression of psychotherapy. If a session extends beyond the scheduled duration, additional fees will apply.

Deposit & Cancellation Policy: To secure your appointment, an $80 deposit is required. You must notify Mellow at least one business day in advance to cancel or reschedule, or your deposit will be non-refundable (including "no-shows"). For example, for appointments on Saturday, Sunday, or Monday, you must provide notice by 6 p.m. (EST) on the preceding Friday.

6. FINANCIAL AGREEMENT & PAYMENT Session fees range from $140 to $210 per hour depending on the assigned therapist. Payment is due at the end of each appointment via Stripe or Interac e-Transfer (EMT). A receipt will be provided for your records and insurance submission. You acknowledge that outstanding fees must be settled before booking future psychotherapy.

 

7. INDIVIDUAL DIFFERENCES & PROCESS

Every individual comes from different educational, cultural, family, and work backgrounds, with their own personality and life values; we respect the differences among everyone and the uniqueness everyone possesses. Since the psychological counseling process often involves an individual’s emotions, stress, changes in self and interpersonal relationships, immigration adaptation, cultural clash, and other problems, the clients has to be prepared, as the effectiveness and time required for counseling are different for every individual. With numerous factors affecting the outcome, counseling services are not able to solve clients' problems in one, two, or three sessions. Clients have to realize the differences between their idealization and reality, and that this is the process necessary for growth and development.

8. SWITCHING THERAPIST

We understand that the therapeutic relationship is crucial for effective psychotherapy. If you feel that you are not a good fit with your current therapist, you may request to switch to another therapist within Mellow Wellness. We will arrange this transfer based on availability and your specific needs.

9. LEGAL MATTERS & DOCUMENTATION

Mellow Wellness does not represent clients in processing any events with legal purposes, nor are we responsible for creating legal reports. In the event you need a letter of confirmation that you have received psychological counseling services from Mellow Wellness, you may request this from your therapist. Please note that a fee applies for the preparation of any written confirmation letters.

By signing below, I certify that:

I have read and understood this Informed Consent document.
I understand the risks and benefits of Telehealth.
I agree to the terms regarding fees, deposits, and the cancellation policy.
I voluntarily consent to engage in psychological services provided by Mellow Wellness.