If or when I avail of counseling/therapy services, I understand that it will be subject to the conditions provided herein below:
1. Confidentiality. Everything taken up during a counseling/therapy session shall be strictly confidential. No party may record (i.e., audio and/or video) the same, or any portion thereof. Any information that I disclose or share during a session shall only be released with my permission, except in the following cases in a manner consistent with applicable laws and regulations:
a. If the psychologist determines risk of self-harm;
b. If the psychologist determines risk of harm to others;
c. If the psychologist is informed about or suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult; or
d. If the psychologist believes that someone's mental condition leaves the person gravely disabled.
Any violation of this confidentiality obligation may be subject to appropriate legal action.
2. Data Protection. If or when personal data is involved, it will be processed pursuant to and in accordance with applicable data protection laws and policies such as Republic Act 10173, also known as the Data Privacy Act of 2012 (DPA), its implementing rules, appropriate issuances of the National Privacy Commission.
3. Risks and Limitations. I am fully aware and understand that:
a. all my issues and concerns cannot be addressed in a limited number of sessions.
b. certain deviations from the agreed treatment plan may happen depending on my current progress and circumstances. I shall have a continuing dialogue with my psychologist regarding this.
4. Duration and Schedule. I understand that a counseling session is typically 60 minutes long and is scheduled ahead of time (at least 24 hours before). Any last minute request for schedule may or may not be accommodated depending on the availability of the psychologist.
5. Service Availability, Payment of Fees, Cancellations and No shows.
We request that payments for all appointments are made within 24 hours from the time of booking.
We value your time, our time & the service that we provide. A grace period of 15 minutes will be permitted for unforeseen delays you or the psychologist may encounter. If you are late, the session will not be extended beyond 1 hr. However, if the psychologist is late, the session is extended to compensate for the delay.
Last minute cancellations cost us if we are unable to replace the appointment. In addition, the psychologist sets aside time and prepares for your appointment. To continue efficient operations, we must strictly enforce our cancellation policy as follows:
a. If you have pre-paid & then need to cancel, we will either refund you in full or transfer the payment to another date if you reschedule, provided we have received adequate notice. We ask that you provide us with as much notice as possible when cancelling or rescheduling. A minimum of 24 hours notice for cancelling or rescheduling of appointments is necessary to avoid cancellation fees.
b. If the session is cancelled by the psychologist due to unforeseen circumstances, pre-payment will be refunded in full or transferred to another date if reschedule is made.
c. For cancellations or rescheduling with less than 24 hours notice, or where a client does not show up for the appointment, a cancellation fee of 100% of the full appointment cost will be charged.
I understand that I must comply with the safety plan of my psychologist to ensure my personal and physical safety. I give my consent to my psychologist to activate my emergency contact should the need arise. I understand my duties and responsibilities in counseling sessions. All my questions about this agreement have been addressed.
By affixing my name and the date on this form, I affirm that I have read and understood the terms and conditions specified in this Form and agree to abide by them.