CLIENT INFORMED CONSENT
SERVICE PROVIDER.
Your Service Provider, MCRRD PSYCHOLOGICAL SERVICES (“Provider”), is a business entity duly registered with the Department of Trade and Industry and is primarily engaged in psychological assessments, counseling, and other mental health services.
MCRRD Psychological Services is represented by its CEO, founder and President, MATTHEW CHRISTIAN ROBERT DOMING, Registered Psychologist.
AFFILIATED PSYCHOLOGISTS
The provider has several affiliated psychologists (“Psychologist/s”) serving as consultants to provide mental health services to our clients. As such, one affiliated psychologist will be assigned to you who will provide you with your needed psychological services.
You may select your preferred psychologists listed on the provider’s website as well as the date and time for counselling.
In instances where your preferred psychologist is not available on your preferred date and time, you may reschedule your counselling appointment on another date and time as agreed upon between you and your preferred psychologist.
Before or after the counselling session, the affiliated psychologist may refer or direct you to other affiliated psychologist if, prior or in the course of the counselling session, he becomes unavailable.
COLLECTION OF PERSONAL INFORMATION
In order to render an effective and efficient psychological service, the provider, through its affiliated psychologists, may gather, collect, store, and record your personal information relevant to your mental health concern which includes, but is not limited to, your name, contact information, medical history, psychological history, behavioral tendencies, and mental health symptoms.
The provider may utilize different means and methods in gathering and collecting you’re relevant information in relation to your mental health concern, which includes, but is not limited to, the following:
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Website Membership Registration: Collects your name, contact information, affiliated company, and emergency contact person.
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Initial Mental Health Screening: Uses the following standardized psychological testing materials: PHQ-9, GAD-7, ASQ, to determine the severity of depression, anxiety, and suicide risk, respectively based on presenting symptoms.
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Intake Form: Collects comprehensive personal information such as medical, personal, family, social, emotional, cognitive, and behavioral history and tendencies. The aim of the form is to assist psychologists in creating an efficient case conceptualization and treatment plan.
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Progress Report: Narrates and summarizes what happened in every counseling session and records your progress based on your treatment plan.
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Treatment Plan: This is a document that contains plan of actions to take in order to help you solve your presenting problems.
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Log sheet: This document logs the history of counseling sessions.
The provider may require you to disclose other personal information in the course of the counselling session.
PRIVACY AND CONFIDENTIALITY
Personal and sensitive information gathered and collected, as part of your assessment and treatment, shall be kept strictly confidential and shall be viewed only by the provider, the psychologist, and persons authorized by law, rules and regulations.
Your personal information and identity shall be stored and recorded with the utmost confidentiality, and may be used by the provider as basis to determine the appropriate psychological service that caters to your need and addresses your concern.
We would like to emphasize that all relevant information gathered, collected, stored, recorded and documented by the provider shall be protected at all times. Your personal and sensitive information may only be viewed by the provider and the psychologist. The said information will not be shared to other persons or organizations without your prior written consent. Furthermore, pursuant to R.A. 10173 or the “Data Privacy Act of 2012”, you may access your personal information at any time upon prior notice to your psychologist or the provider.
The provider and the psychologists follows strict guidelines for professional conduct that is in line with the Professional Regulatory Commission (PRC) and the Psychological Association of the Philippines (PAP) Code of Ethics.
LIMITS OF CONFIDENTIALITY
All personal information gathered by the provider and your selected psychologist/s during shall be kept and remain confidential except in the following instances:
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It is subpoenaed by a court; or
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A well-grounded fear that failure to disclose the information will endanger the life, health, or safety of the public or yourself.
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Your prior approval has been obtained for any of the following purpose:
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Provide a written report to another professional or agency. e.g. GP, school or a lawyer; or
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Discuss the material with another person, eg. a parent, employer or health provider; or
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Disclose the information in another way; or
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You would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected; or
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Disclosure is otherwise required or authorized by law.
Should the information gathered or collected from you indicate a reasonable and well-grounded belief that you may cause harm or injury to yourself or to other people, the provider or your selected psychologists will immediately notify your emergency contact person.
SHARING OF SELECTED PERSONAL INFORMATION WITH YOUR INSURANCE PROVIDER
In instances wherein you engaged the services of the provider through your insurance provider, the provider and your selected psychologist may share certain information to your insurance provider including, but is not limited to; your name, insurance certificate number, affiliated company, and the treatment plan.
CONSEQUENCE OF NOT PROVIDING TRUTHFUL AND COMPLETE PERSONAL INFORMATION
All recommendations, assessment, conclusions, summaries and findings of the provider or the psychologist shall be entirely based on the veracity and truthfulness of the information you provided, hence you are required to disclose all necessary information in to the best of your knowledge.
PAYMENT AND FEES
If you availed any psychological services offered by the provider through an insurance provider, the payment of the professional fees will be shouldered by your insurance provider pursuant to and within the bounds agreed upon by the provider and your insurance provider.
If you engaged in any psychological service with the provider without an insurance provider, you will personally submit your payment to the provider.
CANCELLATION AND CHANGING OF APPOINTMENT SCHEDULES
You may cancel or change the scheduled date and time of your appointment provided that you give your selected psychologist prior notice at least twenty-four (24) hours before the original date of appointment.
WAIVING THE PROVIDER FROM LIABILITIES
The provider shall not be held liable from any malpractice, or any ethical violations as a result of the acts or omissions of the psychologist by reason of the psychological service rendered or in the course thereof.
The provider shall likewise be free from any and all liabilities resulting from the acts or omissions of the psychologist which are contrary to law, good morals, customs, and rules and regulations issued by competent authority
