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DISCLOSURES AND INFORMED CONSENT AGREEMENT
Figure-Ground Well-being Center is deeply committed to privacy, confidentiality, multicultural sensitivity, and quality care. We intend to provide quality psychotherapy services with various approaches. We hope that the issues that brought you into therapy may be resolved as we work together.
Following the Data Privacy Act of 2012, the Professional Disclosure Statement is provided for the client to read before booking. By ticking the consent box on the booking page, the client indicates that she/he has read and understood the information.
Provider information
Figure-Ground Well-being Center consists of therapists and associates from diverse educational backgrounds with varied clinical experiences in mental health. Licensed mental health practitioners who work in our company have a minimum Master’s degree and/or Doctoral degree in Psychology. The Professional Regulation Commission (PRC) licenses them in the field of mental health. As licensed psychologists, they are not allowed to prescribe psychotropic medications but could refer you to a psychiatrist while receiving psychotherapy from our institution.
Length per session
(It may still vary depending on nature of the case)
| Individual or couples therapy | ≈ 50-60 minutes |
| Group counseling | ≈ 60-90 minutes |
Financial requirements
Payment for services: Each individual session amounts to PHP 2,800.00, each couple session to PHP 4,000.00, and each family/group session (3–5 participants) to PHP 5,000.00, payable in full before your session.
Cancellation, missed appointments, late, transfer & refund policy
No-shows and cancellations. Appointments are non-refundable but fully transferable to another individual. The clinic must be notified at least 48 hours prior to the slot with the new patient’s full name and details. We require proper identity verification and medical history clearance for the substitute patient before confirming their slot to comply with health and data privacy regulations (Data Privacy Act of 2012).
Rescheduling. Rescheduling requests must be made at least three (3) days (72 hours) before the scheduled appointment; requests made within seventy-two (72) hours of the appointment may not be accommodated. A maximum of two (2) reschedules is allowed free of charge; beyond that, a fee of PHP 500.00 shall be charged to the client.
Clinician unavailability / clinic cancellations. If the clinic or clinician cancels or fails to attend your scheduled appointment, you will be offered the choice of an immediate reschedule or a 100% full refund.
Late policy. Late arrivals will receive the remainder of their allotted time, as sessions must end on schedule to respect the next patient’s appointment.
Confidentiality
In accordance with the Code of Ethics for Philippine psychologists and applicable laws, your participation in therapy, the content of your sessions, and the information you provide to your psychologist shall be treated as confidential.
When a third person needs to be present during a session, such as an interpreter, caregiver, or other authorized individual, their presence shall require the client’s consent. The third person shall also be required to sign the appropriate confidentiality agreement or consent form and shall be expected to protect all information disclosed or discussed during the session.
Exceptions to confidentiality may apply in the following circumstances:
- When you provide written consent authorizing the release or disclosure of your information to another person, organization, or entity.
- When a psychological or clinical evaluation report is requested for personal, employment, or other authorized purposes. Records or reports may only be released with your written consent using the appropriate consent form provided by Figure-Ground Well-being Center.
- When your psychologist reasonably believes that there is an imminent risk of serious harm to you or another person. Relevant information may be disclosed to appropriate individuals, emergency services, or authorities when necessary for safety.
- When disclosure is required by a valid court order or other lawful process. Information disclosed shall be limited, whenever applicable, to what is relevant to the legitimate request.
- When information relates to an act, threat, or circumstance that the psychologist is legally required or professionally obligated to report.
- When your psychologist has another legal or ethical duty, right, or obligation to disclose specific information.
Use of de-identified data for research & quality improvement
To help us evaluate and improve our mental health services, our clinic periodically analyzes anonymized clinical data. This helps us better understand treatment outcomes and overall therapy effectiveness.
Strict privacy & anonymity. All identifying information (such as your name, contact details, and personal identifiers) will be completely removed. Data is used solely in an aggregated, non-identifiable format.
Completely Voluntary. Consenting to the use of your de-identified data is entirely optional. Choosing not to participate will not affect your access to treatment, quality of care, or relationship with your clinician.
Your choice is made through a separate, optional checkbox on the booking page. If you leave it unticked, your data will not be used for research purposes.
Social media policy
Professional ethics standards do not allow healthcare providers to communicate with clients via personal social media.
Consent for treatment
By ticking the consent box on the booking page, you agree that you have read, fully understand, and given consent to the disclosures, terms, and conditions stated above in this Informed Consent, and that you have been allowed to ask questions.
By ticking the consent box, you are also consenting to participation in services provided by the clinician assigned in your booking.
Third-party attendees (legal guardian, caregiver, interpreter, or other authorized individual) will be asked to sign the appropriate confidentiality agreement or consent form at the clinic before the session.