INTELLECT CARE – Informed Consent Form 

Welcome to Intellect Care (“Intellect” or “Company”). Intellect’s mission is to make mental health care accessible to everyone. Your employer has partnered with Intellect to provide mental health services to you. No matter what your mental health needs are, we are available.

Please read this sheet carefully. This Informed Consent for sessions contains important information about your care with Intellect. Acknowledging this document represents an agreement between us. By signing this Consent you consent to referral via your employer’s well-being manager. Please read this carefully.

Collection and Use of Personal and Health Information

Intellect collects and maintains information related to your health and well-being. All of our network partners, staff, clinicians, counselors, and coaches (“Providers”) are committed to the secure management and maintenance of this information according to applicable laws in Singapore, in particular, the Singapore Personal Data Protection Act 2012 (PDPA).

We collect your personal and health information when you first reach out to book an appointment with Provider/s, and during the period of your care with Intellect. This information enables us to:

• Schedule necessary appointments
• Alter appointments in case of staff unavailability
• Confirm your eligibility for our services through external agencies/clinics/services
• Assess issues related to your presenting concerns, and
• Maintain or improve your psychological health and wellbeing

Obtaining Information About Your Case From Other Professionals Or Agencies

It is often helpful to obtain information from therapists or agencies who may have assessed or treated you in the past. Subject to your prior approval, Intellect may exchange information about you with these individuals or agencies. Intellect may contact your referring doctor in order to clarify the referral or seek an opinion. Intellect will attempt to gain your approval before contacting your referring doctor.

Use of GenAI:

It is helpful to use GenAI in our process. We will use it in compliance with applicable privacy laws and guidelines. By signing this contract, you hereby consent to the use of GenAI to record our clinical sessions between the therapists and you to generate case notes & treatment plans.

Modality of Sessions

Sessions Intellect are conducted either face-to-face in-person or remotely online via tele-health Intellect’s app. Intellect reserves the right to change the modality of sessions from face-to-face to virtual sessions if government regulations and precautionary measures require this (e.g., during the occurrence or resurgence of a pandemic or other similar events).

Confidentiality of Information

Your Provider/s has a legal and ethical responsibility to protect the confidentiality of all communications that occur between you and your Provider/s during and outside your sessions, as well as any information pertaining to your person and care that is obtained for the purpose of your care. All of your session details are strictly private and confidential between you and your Provider. Only session utilizationutilisation will be shared with your organizationorganisation (if any). This will not disclose any information which may identify you.

All information provided to your Provider will be treated in professional confidence. Your case will not be discussed outside formal supervised arrangements. This applies for both face -to-face in-person and tele-health sessions.

Exceptions to Confidentiality

These are scenarios where your Provider may need to break confidentiality by informing other parties about your care or share information about your person, or is obliged to do so by the law:

1. Failure to disclose the information would place you or another person at risk of abuse or harm.
   • cases in which the purpose of such disclosure is clearly in my interests, and if consent cannot be obtained in a timely way
   • assessment and interventions related to my concerns are to be conducted by other health professionals;
2. If a disclosure of facts/incident requires Intellect to submit a report to the necessary regulatory or law enforcement authorities.
3. When your information is subpoenaed by a court and such disclosure  is otherwise required by law.        
4. I have authorized such a releasesuch release in writing or by verbal permission.  

Your Provider will discuss (whenever possible) the matter with you before breaking confidentiality.

Intellect Escalation Protocol

At Intellect, we adopt Intellect Escalation Protocol in the processin process of disclosing confidential information. You agree that you have reviewed the Intellect Escalation Protocol

and hereby consent to such disclosure of confidential information as per the Intellect Escalation Protocol.

Supervision

From time to time your Provider will discuss your case with their supervisor. This is standard practice and serves to ensure that you receive the best possible care with Intellect. Please note, your Provider’s supervisor is bound to the same strict confidentiality policy and cannot disclose any information pertaining to your person or care, with the exception of scenarios specified above.

Fees & Cancellation

The sessions are fully covered by your company. The number of sessions is communicated to you during the launch of Intellect’s services.  Before the entitled sessions are completed, the Provider shall discuss further follow-ups.

• It is important that you attend your appointments on time to achieve maximum results. If, for some reason you need to cancel or reschedule your appointment, please give your Provider at least 24-hour notice.
• Your Provider will regularly review your treatment plan with you, including your goals, progress, and motivation for treatment. Whenever possible, your Provider will jointly discuss with you the need to refer you to a service more suited to your care, or discuss any upcoming discharge from treatment. Likewise, you may also withdraw from therapy at any time.

The above-mentioned applies to both face-to-face and virtual sessions.

Information Used for Other Purposes

Service-wide, statistical, non-identifying material may be generated to allow the planning and provision of services. Intellect may use this material for management, planning, and monitoring, with the aim to improve or evaluate the services we offer. For such purposes, data will be presented as group statistics and no individual data or information will be shared. We may share such data without any individual identification with research bodies investigating well-being, health management, and health promotion initiatives.

Access to Information

You have a right to access your personal information. If you wish to make a formal request to access your information, you need to do this in writing to support@intellect.co

Disclaimer

By signing the Informed Consent, you voluntarily agree Intellect does not recommend, endorse or make any representation about the efficacy, appropriateness, or suitability of any specific tests, products, procedures, treatments, services, opinions, or health care providers. You agree to receive mental health assessment, care, treatment, or services and authorize the therapist to provide such care, treatment, or services at your sole risk.  You acknowledge and agree that Intellect, its officers, partners, service providers, therapists, contractor, or sub-contractor, will not be liable to you, whether by indemnity, by statute, in tort, or any other basis in law or equity, for loss of data, economic loss, punitive or exemplary damages, or any incidental, special, indirect or consequential loss or damage which may be suffered by you in connection with the mental health assessment, care, treatment, or services, including any death or personal injury caused as a result of the services.

Zero Tolerance of Aggressive Behaviour towards Staff

At Intellect, we adopt a strict ‘zero tolerance’ attitude towards any form of violent, threatening or abusive behaviour made towards our staff in person, over the phone, video calls or email. Following any incident, in which any of our staff are abused, threatened or assaulted in the course of their performance of services or work by a client or their relations or associates, Intellect reserves the right to terminate the treatment/case immediately and at its own discretion, may make a report to the incident to the appropriate authorities/police, if warranted by the situation. Aggressive behaviours may include verbal abuse, shouting, offensive or derogatory remarks, verbal threats or physical attacks.

Release of Information (Adult)

I, also agree and give consent for Intellect to contact my company, emergency contact, and/ or the relevant authorities  should any of the following events occur:

• I am uncontactable for more than 48 hours without prior notice, and
• If I disclose that I or someone else may be at risk (whenever possible my Provider will endeavor to give me notice prior to communicating details of my “at risk” disclosure to the contact person(s) or to such third parties as may be deemed necessary).
• Other unforeseen circumstances that raise a reasonable suspicion of risk to myself or others.
• To obtain and/or release any information that may be of relevance or value in my care and treatment.

Unless otherwise indicated under the “remarks” columns, information that may be released to the said persons on a need-to-know basis, may possibly include the release of some sensitive or confidential information about myself, where deemed necessary to ensure my safety and wellbeing.

By continuing, I understand the nature and limits of confidentiality, and what is expected of me as a client of Intellect Services. I agree to indemnify the Company and/or the Provider from any and all actual or alleged claims, demands, causes of action, liability, and/or injury (to property or persons, including without limitation wrongful death), whether brought by me, any individual, or other entity.

Exhibit

Applicable Law