INFORMED CONSENT FORM

I understand that to achieve the best result, I will be sharing sensitive and personal information about myself to a psychologist who will help me cope with my mental health concern/s. I agree to be contactted through email, phone number or any messaging applications.

I understand and agree that Divine Mercy Psychiatric Facility provides an Outpatient Teleconsultation service which has limitations for emergency or urgent cases such as active suicidal ideations, homicidal ideations, and other severe psychological symptoms. For such situations, I agree to seek urgent care at the nearest emergency room or appropriate health center.

Knowing this, I agree that if I avail of Divine Mercy Psychiatric Facility's services, I will not be committing self-harm, am not presently experiencing severe psychological symptoms, and do not have active suicidal thoughts.

I understand that all information shared with Divine Mercy Psychiatric Facility and its representatives will be confidential and no information will be released without my prior knowledge and consent. I understand that there are limits to this confidentiality, including the following:

1. When there is imminent risk to myself or others, Divine Mercy Psychiatric Facility has the ethical responsibility to take necessary steps to prevent such danger by communicating with my emergency contact, relevant professionals or authorities.

2. When a valid court order is issued to release such information, Divine Mercy Psychiatric Facility is legally required to comply.

3. When a consult or referral is made with another mental health practitioner, Divine Mercy
   Psychiatric Facility will ensure the quality and continuity of care.

4. To ensure each client recives the best treatment possible, case discussions and consultations
   may be held within Divine Mercy Psychiatric Facility. All identifying information will be
   removed to safeguard the client's privacy.

I agree to receive emails, texts or message application updates for an online consultation that will last approximately one (1) hour. For other concerns, I may contact Divine Mercy Psychiatric Facility.

CANCELLATION AND NO-SHOW POLICY
We value your time and the time of our mental health professionals. Please review our cancellation and no-show policy below:
Client Cancellations and No-Shows

• If you cancel your appointment with less than 24 hours’ notice or fail to appear without prior notice (“no-show”), a 50% cancellation fee will be charged.

• If you cancel 24 hours or more in advance, you are eligible for a full refund or may reschedule your session at no additional cost.

Provider Cancellations and No-Shows

• If your psychologist cancels with less than 24 hours’ notice or does not show up for your session, you will receive a full refund or the option to reschedule, plus a 5% discount on your next booking.

• If the provider cancels with more than 24 hours’ notice, you may choose to reschedule or receive a full refund.