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INTELLECT CARE – Informed Consent Form for Dependent Access

Welcome to Intellect Care (“Intellect” or “Company”). 

Your employer has partnered with Intellect to provide mental health services to you and your immediate family. Intellect’s mission is to make mental health care accessible to everyone no matter what their mental health needs are.

This Informed Consent for sessions contains important information about the Dependent’s care with Intellect. Acknowledging this document represents an agreement between us. As a parent or legal guardian, please read this Informed Consent Form carefully.

You hereby acknowledge that you are the parent or legal guardian of a minor, and is signed up and currently logged onto Intellect’s Application “Dependent”). You hereby voluntarily consent for the Dependent to take part in the counselling and or coaching sessions and agree to this Informed Consent Form. 

Collection and Use of Personal and Health Information

Intellect collects and maintains information related to the Dependent’s health and well-being. 

All of our network partners, staff, clinicians, counsellors, and coaches (“Providers”) are committed to the secure management and maintenance of this information according to: 

(i) applicable laws in Singapore (in particular, the Singapore Personal Data Protection Act 2012 (PDPA)) and 

(ii) any other applicable data protection law in the jurisdiction where the Dependent are based, in particular the legislation specified in the Exhibit below.

We collect the Dependent personal and health information when you first reach out to book an appointment for the Dependent with Provider(s), and during the period of the Dependent’s care with Intellect. 

This information enables us to:

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

Obtaining Information About the Dependent’s Case From Other Professionals Or Agencies

To provide the best possible care, Intellect may seek your approval to contact the Dependent’s referring doctor to clarify the referral or seek an opinion. Intellect may also seek your approval to request information from therapists or agencies who may have assessed or treated the Dependent in the past. 

Modality of Sessions

Intellect conducts either face-to-face in-person sessions or remote, online telehealth sessions through Intellect’s app. 

Intellect reserves the right to change the modality of sessions from face-to-face sessions 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 Agreement 

The Dependent’s Provider(s) bear a legal, ethical, and professional responsibility to ensure that all details of all sessions are kept private and confidential, along with any information pertaining to the Dependent and care that is obtained for the purpose of the Dependent’s care. 

All information provided to the Provider will be treated in professional confidence. The Dependent’s case will not be discussed outside formal supervised arrangements. This applies for both face-to-face in-person and telehealth sessions.

Only session utilisation will be shared with your organisation, and no information which may identify you or the Dependent will be disclosed.

Exceptions to Confidentiality Agreement

These are circumstances under which the Provider may need to break confidentiality by informing other parties about the Dependent’s care or share information about the Dependent, or is obliged to do so by the law:

  • Failure to disclose the information would place the Dependent or another person at risk of harm.
    • Cases in which the purpose of such disclosure is clearly in yours or your Dependent’s interests, and if consent cannot be obtained in a timely way
    • Assessment and interventions related to your concerns or your Dependent’s concerns that are to be conducted by other health professionals;
  • If a disclosure of facts/ incident requires Intellect to submit a report to the necessary regulatory or law enforcement authorities.
  • When such information is subpoenaed by a court and such disclosure is otherwise required by law.
  • I have authorised permission for release, either verbally or in writing.

Whenever possible, the Provider will discuss the matter of breaking confidentiality with you before doing so.

Intellect Escalation Protocol

We adopt the Intellect Escalation Protocol in the process of disclosing confidential information. 

You agree that you have reviewed the Intellect Escalation Protocol and hereby consent to such disclosure of the Dependent’s confidential information as per the Intellect Escalation Protocol.

Supervision

From time to time, the Provider will discuss the Dependent’s case with their supervisor. This is standard practice and serves to ensure that the Dependent receive the best possible care with Intellect. 

The Provider’s supervisor is also bound to the same strict confidentiality policy and cannot disclose any information pertaining to the Dependent or his/ her care, with the exception of scenarios specified above.

Fees & Cancellation

The following applies to both face-to-face and virtual sessions. These sessions are fully covered by your company, and the number of covered sessions have been communicated to you at the launch of Intellect’s services. 

Before the entitled sessions are completed, the Provider shall discuss further follow-ups, if necessary.

It is important that you attend the Dependent’s appointments on time to achieve maximum results. If you need to cancel or reschedule the session, please give the Provider at least 24-hour notice.

The Provider will regularly review the Dependent’s treatment plan with you, including their goals, progress, and motivation for treatment. Whenever possible, the Provider will jointly discuss with you and your Dependent the need to refer your Dependent to a service more suited to the Dependent’s care, or discuss any upcoming discharge from treatment. Likewise, you may also withdraw the Dependent from therapy at any time.

Information Used for Other Purposes

Intellect may use service-wide, statistical, non-identifying material for the management, monitoring, planning and provision of services with the aim to improve or evaluate the services we offer. 

In such cases, 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 and the Dependent’s personal information. 

If you wish to make a formal request to access your and the Dependent’s information, you need to do this in writing to support@intellect.co.

Disclaimer

By consenting to this Informed Consent, you (as the parent/ guardian) acknowledge that 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 (as the parent/ guardian) consent to the Dependent receiving mental health assessment, care, treatment, or services and authorise the therapist to provide such care, treatment, or services at your sole risk. 

You (as the parent/ guardian)acknowledge and agree that Intellect, its officers, partners, service providers, therapists, contractor, or sub-contractor, will not be liable to you or the Dependent, 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 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. Aggressive behaviours may include, but are not limited to, verbal abuse, shouting, offensive or derogatory remarks, verbal threats or physical attacks.

Following any incident in which our staff are abused, threatened, or assaulted while performing their duties by a client, their relatives, or associates, Intellect reserves the right to immediately terminate the treatment or case. Additionally, at its discretion, Intellect may report the incident to the appropriate authorities or police if the situation warrants.

Release of Information (Dependent)

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

  • The Dependent is uncontactable for more than 48 hours without prior notice, and
  • If the Dependent discloses that the Dependent or someone else may be at risk (whenever possible, the Provider will endeavour 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 of the Dependent’s data as collected by Intellect and the Provider, and what is expected of me as a parent/ guardian of a minor user 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, the Dependent, any individual, or other entity.