Psychotherapy Agreement

I, , consent to psychotherapeutic treatment with the therapist Philipp Chen Tan. I have been provided the necessary information to voluntarily decide consent. I have been duly informed of the therapist’s qualifications, as well as the terms of the therapeutic relationship as follows:

I understand that CONFIDENTIALITY is assured to the best of the therapist’s ability. No personal information will be released without my written permission. However, there are exceptions to which I have agreed:

•In judicial proceedings, whatever its nature, privilege and confidentiality cease when the judge issues a court order for my records.

•If the therapist suspects that I am in danger of harming myself or others, I understand that it is his ethical responsibility to inform the necessary persons to prevent that harm from occurring.

•In cases of child abuse and neglect, and elder abuse and neglect, the therapist reserves the right to inform the authorities involved depending on the level of harm/potential harm. I waive my right to bring a lawsuit against the therapist should the reporting of abuse/neglect cause me legal and financial penalties, assuming that I am at fault for the abuse.

•I have also been told that in cases of complex issues and problems which the therapist cannot handle on his own, he may consult with other psychologists/therapists, medical doctors, and other professionals who may be able to help. However, any identifying information about me will be protected. I understand that psychological consultation is for my own welfare and that it provides the therapist another resource for competent service.

•I understand that if I bring a lawsuit or any legal or administrative complaint against the therapist for whatever reason, my right to confidentiality also ends. I understand that the therapist will need to provide the court with the details of my case to defend himself, as is his right. During such a complaint, the therapist will immediately cease contact and all professional relationships with me and will have the right to refuse access to client records as part of his defense against whatever charges I may make.

In terms of professional RECORDS, I have been informed that the therapist keeps such confidential documents in a secure place and takes the necessary precautions to the best of his ability to prevent them from being destroyed or stolen. I understand that the physical document is the property of the therapist, but the contents are mine by right. The therapist will provide me a summation should I insist on a copy of my records.

However, the physical document itself will not be reproduced to protect against misinterpretation. I am assured that the therapist records only those things that are of relevance based on his clinical opinion and that nothing encoded is meant to be personally disparaging. The therapist will destroy these records if there is any danger of it being misused or falling into the wrong hands to preserve my right to confidentiality.

Regarding FEES, I agree to pay the therapist on time for every session completed. The therapist charges per 50-minute hour session (“therapeutic hour”) depending on the initial evaluation of psychological issues. The therapist charges:

1,000 pesos for counseling/therapy with individual adults and individual minors per therapeutic hour per session

Any deviations from the norm will have to be discussed beforehand with the therapist. I understand that the therapist reserves the right to ask for overdue payment or terminate therapy when intentional non-payment not due to financial circumstance or inability to pay is evident.

If the therapist becomes involved in a court proceeding as a professional or expert, I understand that there is an extra fee to be collected for the purposes of preparing reports and for the therapist’s expert opinion on my case. The fee for such an involvement will be negotiated depending on the context.

The INITIAL SESSION is typically two hours long, devoted to intake and assessment. It has been explained to me that the rest of the sessions are typically fifty minutes long, but may be extended, by which time corresponding fees will typically be collected per fifteen minute-increments beyond the usual therapeutic hour. The remaining ten minutes is provided for the therapist to document the salient points of the session and write down his assessment, as well as to prepare for the next client who comes after me.

I understand that psychotherapy is not a cure-all nor is it an easy road. Thus, I agree to be faithful in my weekly APPOINTMENTS, contacting the therapist at least twenty four hours in advance should I wish to cancel or change my appointment.

I acknowledge that the therapist can only be CONTACTED in a professional manner through his cellphone (via SMS/ text messaging) or through his email during regular business hours (9am – 6pm) and only on weekdays and Saturday mornings. I understand that the therapist does not work on Sundays and holidays, and will not acknowledge any contact from clients during these times. In the event that the therapist cannot be reached, I agree to engage the services of approved therapists found in the therapist’s referral network for emergency counseling. A secondary option open to me is the outpatient department of my nearest hospital for emergency medical services.

I understand that a therapist must keep neutrality and objectivity in order for me to receive competent treatment. Thus, I agree not to engage the therapist in any NON-PROFESSIONAL RELATIONSHIP, keeping in mind that I could be jeopardizing my own treatment. I will not ask the therapist for money or any type of help other than the psychological services contracted. I have also been informed of the dangers of romantic and sexual relationships with therapists.

I understand that within the therapeutic room, I can be as expressive or as withdrawn as I want with no pressure applied by the therapist. I agree not to cause HARM to the therapist and any staff employed, destroy clinic property, or cause a commotion or disturbance in the area of the clinic should I feel anger or rage. I understand that no guarantees can be made when it comes to psychotherapy. The therapist has informed me that things typically get worse before getting better in psychotherapy, and so it is up to me to be patient and cooperative with treatment. I realize that I have the right to empathic and competent treatment without discrimination and prejudice. The therapist has the obligation of providing me with the risks and benefits of my treatment plan and to provide me with referrals and alternatives should I ask for them.

I understand that the therapist considers clients below 18 years old as MINORS and will require a parent’s/guardian’s consent to treatment. If I am such a parent/guardian, I agree to always accompany the child/minor to session and to wait outside the treatment room and not interfere with the therapist’s work. I understand that I may be disrupting the flow of therapy if I do so. I recognize that I am allowed inside the treatment room only at the therapist’s invitation, or if the therapist calls for a family session (instead of a child session/session with minor). I understand the therapist will refuse to treat my child should there be no accompanying parent/legal guardian together with the child in the premises of the clinic.

Confidentiality of minors is maintained, and the therapist reserves the right to inform parents/guardians only of those things revealed in a child session/session with minor that endanger the life of the minor or the lives of others. Pregnancy among female minors will not be revealed by the therapist to the parents/guardians, unless there are complications confirmed by a physician. As a parent/guardian, I am assured that the therapist will regularly provide me with progress updates.

With regard to the records of minors, both parent(s)/guardian(s) and child/minor (if the child/minor meets therapist’s criteria for mature discernment) must unanimously agree for the release of such records. In cases of divorce/annulment/legal separation, if custody is divided, only the parent with legal custody gains the right to petition for records. However, the non-custodial parent retains the natural right to ask for progress updates, with the awareness of the custodial parent. I have also been informed by the therapist that couples

sessions or even family sessions are to be expected in conjunction with sessions with minors. Consultation policy and summation of records released to clients follow the above-discussed statements.

If I am a member of a FAMILY OR COUPLE system that the therapist will treat as clients, I understand that the therapist will conduct family/couple as well as individual sessions with the members involved. Any information revealed in the individual sessions is encouraged by the therapist to be presented to the rest of the parties involved, but the therapist will not force such disclosure. The therapist does not believe that family and couple secrets are productive in the long run.

I also understand that basic rules of courtesy must be followed such as not interrupting someone who is talking. I agree to a no-aggression policy, physically and verbally. If I feel that I am beginning to lose control of my emotions and might do damage, I will excuse myself from session and leave the room until such a time that I can discipline myself and re-enter the room. I agree to keep all information about what goes on in the family or couple session confidential and will not betray the trust of the other member(s). I acknowledge that summations of couple and family records are released only with the unanimous consent of every member involved, aside from the confidentiality limits discussed above.

I reserve the right to TERMINATE the therapeutic relationship for whatever reason. Should I wish to terminate, I agree to inform the therapist of this decision at least a month ahead to properly end without negative feelings on both sides as well as to collate and organize the positive and negative things I have gained through my professional relationship with the therapist. The therapist also has the right to terminate the therapeutic relationship, and I acknowledge this. The therapist has the duty to inform me of the reason of such termination, and to inform me ahead of time as well.

Upon termination, the therapist will follow one of two paths: if I intend to continue my therapy with another counselor or therapist, the therapist will attempt to coordinate directly with the new therapist. If I intend to stop therapy for awhile, the therapist will consider my case to be “closed” after six months of inactivity from the last session. Records will still be retained in case I choose to return or may need the therapist to coordinate with another therapist of my choosing. The ideal termination scenario is the completion of my therapeutic goals, by which time the therapist will keep my records for a maximum of seven years, after which my file will be destroyed to avoid falling into the wrong hands. I also understand that upon reaching the seventh year of inactivity of my records, the therapist will destroy my records. Records will also be destroyed ahead of time (i.e., before seven years are up) if unforeseen circumstances arise which necessitate such actions (e.g., therapist leaving the country for extended periods of time, client migrating, etc.). I have been reminded that the physical document is the property of the therapist, thus at no time do I have the right to claim my physical file.

This agreement is in compliance with the requirements of the ethical standards expected of the therapist’s profession. The therapist reserves the right to make changes to this contract but I hold the right to be informed of such changes. By signing below, I acknowledge that all my questions have been satisfactorily answered and I agree and consent to all the terms described above.

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