CONSENT TO PARTICIPATE IN ONLINE BRIEF PSYCHOLOGICAL SERVICES

PURPOSE iii. Compliance to Commitment to Treatment

agreement between client and Counselor,
The purpose of this form is to obtain consent from the client to
iv. Activation of emergency contact, social support
participate in online brief psychological services with a system, and safety watch, and
psychologist-in-training (“BPS Provider”) affiliated with the
Ateneo Bulatao Center for Psychological Services (“Center”). v. Other procedures and interventions necessary for
the situation.
NATURE OF BRIEF PSYCHOLOGICAL SERVICES
Brief psychological services may not be appropriate for
(a) individuals with active suicidal or homicidal
The Ateneo Bulatao Center offers brief psychological services
thoughts, (b) individuals who are experiencing acute
that are focused on the goal of promoting mental health and the
mental health problems such as manic and psychotic
well-being of the client. The online brief psychological service
symptoms, or (c) individuals who are currently abusing
involves the use of video, audio, or other electronic
psychoactive substances.
communications to interact with the client for the purpose of
attending to the client’s psychological well-being.
Given the nature and limitations of online brief
psychological services, some individuals are not likely
A. Benefits
to benefit significantly from it. Brief psychological
services, therefore, is an option only during times when
The benefits of online brief psychological services include a face-to-face session and/or long-term online
ensuring that mental health treatment can be provided free counseling are not accessible.
of cost to clients in distress when face-to-face sessions are
not accessible. The online set-up offers the BPS Provider 2. The Center is not a medical institution.
and the client the benefit of convenience, since the service
can be offered without needing to travel to a particular Because we are not a medical institution, we are not
location. equipped to handle psychiatric emergencies, and we
do not issue certifications of clinical categorical
B. Limitations and Risks diagnoses or prescribe medication. However, your
BPS Provider may provide you with a list of referrals for
1. The Center’s online counseling is not a crisis- competent psychiatrists upon request.
based clinical service.
3. Security risk with the use of technology.
Ateneo Bulatao Center’s online counseling is not a
crisis-based clinical service or a 24/7 crisis hotline. Online counselors will use basic/free-to-use versions of
As such, sessions must be scheduled ahead of time commercially available video conferencing platforms
and on a by-appointment basis. BPS Providers are (i.e. Zoom) and electronic mailing platforms (i.e.
not readily accessible outside of the scheduled Gmail). These may not be end-to-end encrypted and
appointments. may not be compliant with international data privacy
laws (such as GDPR and HIPAA). As such, these
Furthermore, it is your responsibility to inform your platforms are subject to data security and
counselor if you are at risk of harm to self or confidentiality limitations. In rare circumstances,
others. If a client who was not formerly at risk should platform security features could fail causing breaches
become at risk (such as harm to self or others), this in client privacy and confidentiality.
must be immediately reported to the BPS Provider.
CLIENT
At intake, reports of being at risk of harm to self or
others shall be handled by the counselor following a The online counseling service is exclusively provided to the
standardized safety plan that may include some or all main client only. Family/feedback sessions or case conferences
of the following: must be requested and scheduled separately with separate
fees. Furthermore, the service is available only to adult clients,
i. Referral/Order to proceed to medical/psychiatric aged 18 and above. Minors aged 17 and below and dependent
specialists within your vicinity, adults with neurodevelopmental needs are not eligible to receive
ii. Referral to/Order to contact crisis centers or the service.
hotlines,
Additionally, please note that we do not offer online brief 3. Lapses in confidentiality that are caused by client’s
psychological services to clients who are outside of the decisions and actions in terms of use/misuse of
Philippines. We may accept clients from ASEAN member technology.
nations under the following circumstances: (1) the client has
specified an emergency plan and an emergency contact within 4. Lapses in confidentiality that are caused by client’s
his or her country of residence, and (2) the client has an existing decisions and actions in terms of physical location and
mental health provider within his or her country of residence. venue, such as intrusions or interruptions during the
However, the Center reserves the right to refuse admitting session.
clients who are located outside the Philippines for the protection
of both the client and the Center. F. Disconnection Problems: If video services are not available
due to an unplanned equipment or service malfunction,
ETHICS AND CONFIDENTIALITY sessions can be rescheduled at a later time or date,
depending on the availability agreement and the
A. All personnel affiliated with the Center uphold utmost ethical preferences of both the BPS Provider and client.
standards and confidentiality. As records (both written and
digital) are essential, all information given are securely EDUCATIONAL AIMS OF THE ATENEO BULATAO
stored and can only be accessed by personnel affiliated with CENTER
the Center. Confidentiality is suspended under the following
circumstances: The Ateneo Bulatao Center is the training, research, and service
arm of the Psychology Department of the Ateneo de Manila
1. When there is serious, known, and foreseeable harm University.
to yourself or others;
As the training and service arm of the Psychology Department,
2. When instances of abuse, in any form, are currently
the Center aims to enhance the development of its consultants
being committed against a vulnerable person (e.g.,
and psychologists-in-training. In line with this aim, the Brief
child, elder; employee, woman, mentally ill, etc.);
Psychological Service program was launched in order to give
3. A court order is issued or when such release is required psychologists-in-training an opportunity to hone their skills and
by law; to serve the public. BPS Providers are carefully screened and
selected from a pool of Counseling graduate students who have
4. When your mental health is gravely disabled, or successfully completed a basic course in Counseling &
5. You authorized such release in writing. Psychotherapy. They then undergo additional training in a
variety of counseling techniques in the context of a brief
PROCEDURES FOR ONLINE BRIEF counseling session. As part of their training prior to obtaining a
license, they are required to practice under the regular
PSYCHOLOGICAL SERVICE
supervision of a licensed psychologist. Rest assured that all
BPS Providers are required to adhere to the standards of ethics
A. You will be sent a Zoom link as the video-conferencing
and confidentiality as mandated by the Center, the Mental
platform selected your virtual sessions. You will be given
Health Law, and the Psychological Association of the
instructions on how to use it.
Philippines.
B. You are responsible for securing your own computer with
As an additional part of the Center’s training and research
webcam/mobile phone hardware, internet access points,
function, if you have consented to join the research study,
and password security.
sessions may also be observed or audio-visually recorded. Your
consent to participate in the study will be formally obtained
C. It is your responsibility to take the online session in a
through your consent to participate in the Entry Form and
physical space where psychological safety and
verbally by your counselor.
auditory/visual privacy can be obtained. This entails being
in a quiet and private space that is free from intrusions or
Rest assured that you have the right to refuse the recording, and
distractions (including cell phone or other devices) during
that your verbal and written consent will be obtained prior to any
the session. Should you be unable to respect the BPS
recording. If you do consent, you may also request your
Provider and maintain safety and privacy, the call may be
counselor to stop or discard the recording at any time, for any
terminated according to the discretion of the BPS Provider.
reason. Every effort will be made to ensure professional
confidentiality and that any use of audio tapes, transcriptions of
D. It is important to use a secure internet connection rather
audio tapes, or descriptions of audio tapes, will be for
than public/free Wi-Fi.
professional purposes only and in the interest of enhancing
E. The Center and the counselor are not liable for the either the quality of care you receive or improving professional
standards through research or training programs. At any point in
following:
time, you may withdraw permission from the use of materials
1. Client’s equipment failure, e.g. camera, and/or Internet used or participation in any study. All recordings and transcripts
service. will be destroyed one year after the publication of the study.

2. Confidentiality breaches when they are caused by client USE OF PROFESSIONAL RECORDS
error.
BPS Providers at the Center may take notes and maintain
records of therapy sessions for documentation. These notes will
be used for monitoring sessions and client progress. Client holidays and University holidays. Electronic messages sent to
information (i.e., client-identifiable images or audio-visual our primary email account and mobile number will be
recordings) shall not be disseminated without your consent. entertained during our operating hours. Since the Center is not
a crisis or emergency hotline, the office staff are not readily
Please note that while you are entitled to viewing your records, available outside of operating hours, and we may not
the Center reserves the right to withhold documents should your immediately respond to emergency calls. Additionally, since our
counselor deem that the information may be harmful to your staff are working from home due to the limitations of the
health or your progress. In cases where you may need direct pandemic, there may be delays in response due to mobile signal
access to the full records, they can be made available to a and internet connection issues.
mental health professional of your choice.
LATE OR MISSED APPOINTMENTS AND
All collected information shall be stored either in locked storage CANCELLATIONS
spaces or in password protected digital portals. These shall be
stored for two (2) years from your last session. It is important to be on time. The session will be considered
cancelled or missed beyond the 15 minutes time allowance.
LEGAL REQUIREMENTS, PROCEEDINGS AND Cancellations are allowed at least 2 days (before 2 pm) of their
RIGHTS scheduled online appointment. A new session may be
rescheduled up to 2 times per appointment, regardless of the
The BPS Providers of the Center are not forensic experts nor reason (e.g., internet connection issues, or the client was more
trained to testify in court. Information gathered during online than 15 minutes late to the session). Should the client cancel
brief psychological sessions are not designed for the purpose of for the third time, the client will have to sign up again and
legal proceedings. be waitlisted for an appointment.

If you have questions or concerns regarding your BPS Provider FEES AND CONTINUING SESSIONS
or your treatment, please contact the Ateneo Bulatao Center at
[email protected]. The Brief Psychological Service is a FREE online service each
individual may avail for up to a maximum of two (2) sessions.
OPERATING HOURS Should an individual need further support and reach out again
for additional free sessions, our front desk will refer them to our
Our operating hours are on Wednesdays to Saturdays from paid psychotherapy service or to the appropriate mental health
8:00AM-12:00NN and 1:00PM-5:00PM. We are closed on services for more appropriate professional care.
 INFORMED CONSENT FORM
SAFETY PLAN FOR EMERGENCY. Due to the physical limitation of access to you during times of emergencies, designated emergency
contact/s is/are required. This can be trusted people who is/are near or within your vicinity and may be available to go to you in person,
should the need arise. This trusted person or these trusted people need to be non-minors, or aged 18 years old and above.

A. Kyle Caracas
Name: _____________________________ 09158215047 Relationship: ________________________
Contact No. _________________ friend
B. Name: _____________________________ Contact No. _________________ Relationship: ________________________

C. Name: _____________________________ Contact No. _________________ Relationship: ________________________

By signing this document, I agree to abide by the following:

/
❏ I have read and understood the Informed Consent Form.
/
❏ I agree to the terms and policies outlined in the Informed Consent Form.
/
❏ I understand that the Online Brief Psychological Services are NOT a substitute for psychotherapy.
❏
/ I understand that I may avail of up to a maximum of two (2) brief psychological sessions only.
❏
/ I give my consent to the Ateneo Bulatao Center for Psychological Services to handle and process my personal data.
❏
/ I ascertain to the truthfulness and completeness of the information I have provided Ateneo Bulatao Center in the Entry
Form, and the Ateneo Bulatao Center is not liable for any omissions of relevant information on my end. This information
includes and is not limited to:
/
❏ the emergency contact information I have provided; and
/
❏ my current mental/emotional state.
❏
/ I understand that the online brief psychological service is not applicable for all.
❏
/ I understand the risks and limitations to online brief psychological service.
❏
/ I understand my duties and responsibilities with online brief psychological service.
/
❏ I understand that I must comply with the safety plan of my BPS Provider to ensure my personal and physical safety.
❏
/ I certify that my emergency contact(s) are at least 18 years of age and above.
/
❏ I give my consent for my BPS Provider to activate my emergency contact should the need arise.
❏
/ I agree to allow my BPS Provider to take notes during the session for the purposes of monitoring and tracking my sessions.
❏
/ All my questions about this agreement have been addressed.

Jermaine Nicole A. Barce

___________________________________ ___________________________________
Full Name and Signature of Client Full Name and Signature of BPS Provider

15th August 2023

______________________________ ______________________________
Date Signed Date Signed
 APPENDIX: CLIENT RIGHTS ACCORDING TO RA 11036
CHAPTER II (j) Access to adequate information regarding available
multidisciplinary mental health services;
RIGHTS OF SERVICE USERS AND OTHER STAKEHOLDER
(k) Participate in metal health advocacy, policy planning,
Section 5. Rights of Service Users. - Service users shall enjoy, legislation, service provision, monitoring, research and
on an equal and nondiscriminatory basis, all rights guaranteed evaluation;
by the Constitution as well as those recognizes under the United
Nations Universal Declaration of Human Rights and the (l) Confidentiality of all information, communications, and
Convention on the Rights of Persons with Disabilities and all records, in whatever form or medium stored, regarding the
other relevant international and regional human rights service user, any aspect of the service user's mental health, or
conventions and declarations, including the right to: any treatment or care received by the service user, which
information, communications, and records shall not be disclosed
(a) Freedom from social economic, and political discrimination to third parties without the written consent of the service user
and stigmatization, whether committed by public or private concerned or the service user's legal representative, except in
actors; the following circumstances:

(b) Exercise all their inherit civil, political, economic, social, (1) Disclose is required by law or pursuant to an order
religious, educational, and cultural rights respecting individual issued by a court of competent jurisdiction;
qualities, abilities, and diversity of background , without
discrimination on the basis of physical disability, age, gender, (2) The service user has expressed consent to the
sexual orientation, race, color, language, religion or nationality, disclosure;
ethnic, or social origin;
(3) A life-threatening emergency exists and such disclosure
(c) Access to evidence-based treatment of the same standard is necessary to prevent harm or injury to the service user or
and quality, regardless of age, sex, socioeconomic status, race, other persons;
ethnicity or sexual orientation;
(4) The service user is a minor and the attending mental
(d) Access to affordable essential health and social services for health professional reasonably believes that the service
the purpose of achieving the highest attainable standard of user is a victim of child abuse; or
mental health;
(5) Disclosure is required in condition with an
(e) Access to metal health service at all levels of the national administrative, civil, or criminal case against a mental
health care system; health professional ethics, to the extent necessary to
completely adjudicate, settle, or resolve any issue or
(f) Access to comprehensive and coordinated treatment controversy involved therein;
integrating holistic prevention, promotion, rehabilitation, care
and support, aimed at addressing mental health care needs (m) Give informed consent before receiving treatment or care,
through a multidisciplinary, user-driven treatment and recovery including the right to withdraw such consent. Such consent shall
plan; be recorded in the service user's clinical record;

(g) Access to psychosocial care and clinical treatment in the (n) Participate in the development and formulation of the
least restrictive environment and manner; psychosocial care or clinical treatment plan to be implemented;

(h) Humane treatment free from solitary confinement, torture, (o) Designate or appoint a person of legal age to act as his or
and other forms of cruel inhumane, harmful or degrading her legal representative in accordance with this Act, except in
treatment and invasive procedures not backed by scientific cases of impairment or temporary loss of decision-making
evidence; capacity;

(i) Access to aftercare and rehabilitation when possible in the (p) Send or received uncensored private communication which
community for the purpose of social reintegration and inclusion; may include communication by letter, telephone or electronic
means, and receive visitors at reasonable times, including the
service user's legal representative and representatives from the
commission on Human Rights (CHR);

(q) Legal services, through competent counsel of the service

user's choice. In case the service user cannot afford the service
user cannot afford the service s of a counsel, the Public
Attorney's Office, or a lega; aid institution of the service user or
representative's choice, shall assist the service user;

(r) Access to their clinical records unless, in the opinion of the

attending mental health professional, revealing such information
would cause harm to the service user's health or put the safety
of others at risk. When any such clinical records are withheld,
the service user or his or her legal representative may contest
such decision with the internal review board created pursuant to
this Act authorized to investigate and resolve disputes, or with
the CHR;

(s) Information, within the twenty-four (24) hours of admission to

a mental health facility, of the rights enumerated in this section
in a form and language understood by the service user; and

(t) By oneself or through a legal representative, to file with the

appropriate agency, complaints of improperties, abuses in
mental health care, violations of rights of persona with mental
health needs, and seek to initiate appropriate investigation and
action against those who authorized illegal or unlawful
involuntary treatment or confinement, and other violations.

Section 6. Rights of Family Memebrs, Carers and Legal

Representatives.- Family members, carers and duly designated
or appointed legal representative of the service user shall have
the right to:

(a) Receive appropriate psychosocial support from the relevant

government agencies.;

(b) With the consent of the concerned service user, participate

in the formulation, development and implementation of the
service user's individual treatment plan;

(c) Apply for release and transfer of the service user to an

appropriate mental health facility;

(d) Participate in metal health advocacy, policy planning,

legislation, service provision, monitoring, research and
evaluation.