Michael Page EAP Programme Michael Page EAP Programme Psynamo Adult Intake Form Confidentiality & Consent Confirm & Submit Psynamo Adult Intake Form Full Name Email Address Mobile Phone Number Home Address Birthdate Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Place of Birth Preferred Language(s) Nationality(ies) Gender Female Male Other Highest Education Achieved Secondary School Undergraduate Postgraduate Specialist Qualification Time Lived in Hong Kong? Any Diagnoses, Medications, Health Issues, Therapy? Any ER Visits, Surgeries, Major Events? Allergies & Intolerances? Referral Reason Top Concerns in your Life I confirm my consent for themes emerging from these sessions to be anonymously shared back with Michael Page company. I consent Confidentiality & Consent OUR PRIVACY AND CONFIDENTIALITY POLICY Collection and Use of Personal Information: Our privacy policy reflects both our voluntary adherence to the ethics prescribed by the majority of mental and allied health professional membership-based organisations worldwide and our full compliance with all regulatory requirements. We only collect information about you to identify personal information, to obtain consent for services, to maintain records for the benefit of all parties, to inform services carried out for your support and for the legal requirements of those receiving assessment services and for tracing defaulters. Release of Personal Data: Personal data will only be released to third parties where express written consent has been specifically granted by yourself, where such disclosure is allowed under the Personal Data (Privacy) Ordinance or where we may be legally required to do so by direct court order. Data will only be disclosed to parties where express written consent has been given to such disclosure or where such disclosure is allowed under the Personal Data (Privacy) Ordinance. A fee may be imposed for complying with this data request. The provision of personal data is voluntary, however, if insufficient or incorrect information is provided, Psynamo Limited may not be able to provide the most beneficial or complete services and does not accept responsibility for results based upon such information where it is incorrect or insufficient as provided by the client. Access to Personal Data: You have the right of access and correction with respect to personal data as provided for in sections 18 and 22 and Principle 6 of Schedule 1 of the Personal Data (Privacy) Ordinance. Enquiries concerning any personal data provided, including the making of access and corrections, should be directed during office hours by telephone on +852 9676 6506, by email on admin@psynamo.com or by post to; Suite 1205/6, Car Po Commercial Building, 18-20 Lyndhurst Terrace, Central, Hong Kong. Consent for Data Collection and Retention: I confirm that the information provided here is true and accurate. I give my consent that the above information may be submitted to and kept by Psynamo Limited and to be used in the process of arranging for invoicing and regular communications as they pertain to the services for which I have agreed to engage. I understand that all information provided will be kept in strictest confidence. OUR CONSENT TO TREATMENT Receiving Psychological Services: Working with a mental health professional is a unique endeavor and represents an important relationship based on mutual respect and trust. All psychotherapeutic support and assessment services are completely confidential, non-judgmental, are held within a therapeutic framework of the practitioner, and do not represent advice, medical or otherwise, emergency support services, or any other form of practice. The content of sessions and therapeutic work may bring up uncomfortable feelings and may feel challenging at times. Treatment effectiveness varies from person to person and each therapist will utilise their preferred approach only for your benefit. Sessions/Fees: All sessions commence on the hour and appropriate fees are payable on the day of your appointment. Individual sessions are held for 50 minutes and couples/families sessions are held for 75 minutes (1.5 sessions). We require 24 hours advance notice (before 5pm on Fridays for Monday appointments) for cancellation or change of appointment for no fee to be incurred. Confidentiality of Sessions: Documentation collected during the course of psychotherapy and/or assessments forms are retained by your therapist for the benefit of case conceptualization, planning, and measuring progress towards your therapy focus. This may include background information, data released from third parties or produced as part of any assessment, as well as ongoing notes of the therapist. This data is destroyed three (3) years post-therapeutic termination. Regular supervision and case consultation is required of all therapists but case information is always limited to pertinent details and no names are released apart in circumstances where confidentiality must be breached as a professional standard, including the case of harm to self, harm to others, or actual or suspected minor or elder abuse/neglect is revealed in session and in the case of subpoena by a judge in the Hong Kong court systems. Consent to treatment is an ongoing process and your therapist will always discuss changes to agreements as they arise. We do not provide statements/representations/reports for legal/forensic purposes. In the case that you are receiving support through our eTherapy services, all of the foregoing applies and additionally, no recordings are to be made by the therapist or the client, without express written permission by both parties. It is acknowledged by all parties that there are currently no known jurisdictional boundaries on the provision of virtual psychotherapeutic support in the Asia-Pacific Region, but if this came into effect, the therapist would make the client aware of this as soon as is reasonably practicable and would make arrangements for any required updates to the provision of continued therapeutic support. Confirm & Submit 2 + 8 = Confirmation of Form Submission I confirm the details I have completed on this form are correct. Therapist Assigned Joe Clark Christine Meaney Nicole Stroud Elena Kisel Dr Janet Lau