Intake Form

NATURE OF ONLINE COUNSELING. Online counseling involves the use of video, audio, or other electronic communications to interact with the client for the purpose of attending to the client's psychological well-being.

It is important to note that online counseling offered is not a 24/7 crisis hotline. As such, sessions must be scheduled ahead of time and on a by-appointment basis. Counselors are not readily accessible outside of the scheduled appointments.

If the counselor determines that due to certain circumstances, online counseling will not be beneficial to the client, the therapist may recommend for face-to-face sessions when possible. In case face-to-face sessions are not yet possible, the counselor will help client explore alternate sources of support that may be more appropriate for the time being.

The online counseling service is exclusively provided to the main client only. Family feedback sessions or case conferences must be requested and scheduled separately, with subsequent, separate fees.

CONFIDENTIALITY. The counselor is upheld by utmost ethical standards and confidentiality. As records (both written and digital) are essential, all information given are securely stored and can only be accessed by the therapist. Confidentiality is suspended under the following circumstances:

When there is serious, known, and foreseeable harm to yourself or others;
When instances of abuse, in any form, is currently being committed against a vulnerable person (e.g., child, elder, employee, woman, etc.);
A court order is issued or when such release is required by law;
When the client's mental health is gravely disabled, or
The client authorized such release in writing.

RIGHTS. At any point in time, the client is free to discontinue availing of online counseling. Conversely, if the counselor judges their incompatibility in assisting client with their concerns, the counselor will inform client and refer to another professional who may better meet their needs, which may or may not be accessible online.

CLIENT INFORMATION AND RECORDS. Client information (i.e. client identifiable images) shall not be disseminated without your consent.

RECORDINGS. Taking of audio and video recordings, screenshots, or pictures of the online session are prohibited.

PSYCHOLOGICAL SAFETY AND PRIVACY. It is the duty of the client to take the online counseling session in a physical space where psychological safety and auditory/visual privacy can be obtained. The counselor is not responsible for lapses in confidentiality that are caused by client's decisions and actions in terms of physical location and venue, such as intrusions or interruptions during the session.

NO SHOWS OR LATE CANCELLATIONS. It is important to be on time. Cancellations are allowed at least 48 hours of your scheduled appointment. Cancellations done within 48 hours of the booked appointment and no-shows will incur a 100% session fee.

Client Intake Form

1. Basic Information

2. Primary Concerns

3. Relationship & Sexual History

4. Safety & Boundaries

5. Health & Lifestyle

6. Informed Consent

Thank you, your Intake form has been received.