Patient Consent

I,the patient, hereby provide my informed consent to engage in a mental health consultation with a mental health service provider at iPsych, referred to as “the Provider” in this document. I understand and agree to the following terms and conditions:

1. Purpose and Nature of Consultation:
I understand that the purpose of the consultation is to receive mental health services from the Provider at iPsych. These services may include, but are not limited to, assessment, diagnosis, counseling, therapy, and treatment planning.

2. Confidentiality:
I understand that all information shared during the consultation will be kept confidential to the extent allowed by law and professional ethics. The Provider will not disclose any information without my written consent unless legally required to do so. However, I acknowledge that there are exceptions to confidentiality, which include situations where the Provider determines that there is a risk of harm to myself or others, cases of suspected abuse or neglect, or as mandated by a court order.

3. Treatment Risks and Benefits:
I understand that the consultation involves discussing personal and sensitive information, which may bring up emotional discomfort or distress. However, I also understand that seeking mental health services can provide me with the opportunity for personal growth, improved coping skills, and enhanced well-being.

4. Treatment Alternatives:
I acknowledge that the Provider may discuss various treatment options during the consultation. I understand that I have the right to ask questions, seek clarification, and request information about alternative treatment approaches. It is my responsibility to make an informed decision regarding my mental health care.

5. Professional Boundaries and Code of Conduct:
I understand that the Provider is a licensed professional and will maintain appropriate professional boundaries during the consultation. The Provider will adhere to the ethical guidelines and code of conduct established by their profession’s regulatory bodies.

6. Duration and Frequency of Consultation:
I understand that the duration and frequency of the consultation will be determined by the Provider, based on my individual needs and the treatment plan we establish together.

7. Financial Responsibility:
I acknowledge that I am responsible for the financial costs associated with the mental health consultation. I understand that payment is due at the time services are rendered, and I will be provided with information regarding the fees and payment options.

8. Cancellation and Rescheduling:
I understand that it is my responsibility to provide at least 6 (six) hours notice for cancellations or rescheduling of appointments. Failure to provide adequate notice may result in a fee or forfeiture of the appointment slot. I acknowledge and agree that failing to show up within 20 minutes of my scheduled appointment time will result in forfeiture of the payment made for that appointment. Additionally, I understand that if I arrive late for my consultation, the duration of the session may be shortened by the amount of time I was tardy. It is my responsibility to ensure punctuality and adhere to the scheduled appointment time to optimize the allocated consultation time.

9. Rights and Limitations:
I acknowledge that I have the right to ask questions, express concerns, and actively participate in decisions regarding my mental health care. However, I understand and accept that the clinician has the expertise to determine the appropriate medications and certifications that may be prescribed or written. It is important for me to respect their professional judgment and recommendations.

Furthermore, I acknowledge that if my behavior during the consultation is deemed inappropriate, disruptive, or poses a risk to the safety of the clinician or the therapeutic process, the Provider reserves the right to terminate the consultation.

10. Termination of Services:
I understand that either party has the right to terminate the consultation at any time. If the Provider determines that the consultation is no longer beneficial or appropriate for my needs, they will discuss this decision with me and provide appropriate referrals for continued care.

11. DISCLOSURE 

Additionally, I understand that I may ONLY disclose my medical information to a specific individual or company, provided that I provide a written notice to iPsych Inc., specifying the name of the individual or company to whom I authorize the disclosure, and ensuring that such request is in compliance with the Data Privacy Act of the Philippines.