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Registration Form
For Individual Therapy (Online)

Please take a moment to fill out the form.

Gender
Nationality
Ethnicity

Emergency Contact

Screening Questions

We collect this information to be able to provide better service to our clients and ensure their safety.

Regardless of your answers below, it is important to remember that seeking therapy is a proactive step towards self-care and personal growth, and therapy is available for anyone who is interested in improving their emotional well-being. Your personal struggles and experiences are always valid and we are here to help.

Have you actually had any thoughts of ending your life?
Have you started to work out or worked out the details of how to end your life? Do you intend to carry out this plan?

Informed Consent

Introduction
Thank you for considering our therapy services. Before proceeding, we want to ensure that you have a clear understanding of our services, your rights, and our policies. Please read this informed consent form carefully and feel free to ask any questions that you may have.

Purpose of Therapy Services
The purpose of therapy services is to assist you in improving your emotional and mental well-being. The therapy process involves exploring your thoughts, feelings, and behaviors in a safe, non-judgmental, and confidential environment. The therapist will work collaboratively with you to help you identify and achieve your therapy goals.

Cancellation and rescheduling policy
Any cancellation or rescheduling of sessions must be done 24 hours before the allocated session by contacting us via email or WhatsApp. Cancellations with less than 24 hours notice will be charged the full session fee. Excessive missing of appointments will result in a reevaluation of our contract and your continuation in therapy. The therapist reserves the right to terminate the therapeutic relationship in the event that two (2) consecutive appointments are missed without notification of cancellation. Please note that consistency in therapy, and attending each session will provide you with the optimum potential to benefit from your therapeutic experience.

Payment
The fee per session with the Therapist will be at the agreed rate as displayed on the website. Full payment for the session(s) must be made to confirm the therapy session. 

Contract of service
I acknowledge that the contract of service is between myself and my Therapist and any payments made through such manner as may be notified by Breakthrough Mental Health Services.

Confidentiality
All information that you share with your therapist will be kept confidential and will not be shared with anyone without your written consent, except as required by law. This includes information shared during therapy sessions, as well as any written or electronic records related to your therapy.

Exceptions to Confidentiality
There are certain circumstances under which your therapist may be required to breach confidentiality. These include:
• If you pose a serious threat of harm to yourself or others
• If ordered by a court of law
• If you are a minor under the custody of a legal guardian

Supervision and Quality Assurance
Your therapist may be supervised by a licensed supervisor or participate in peer consultation groups. During these meetings, your therapist may share information about your therapy for supervisory or quality assurance purposes. However, your identity will be kept confidential and any information shared will be de-identified to the extent possible.

Access to Records
Your therapist may keep written or electronic records related to your therapy, which will be kept confidential. However, in the interest of quality assurance and supervision, your therapist's supervisor or Breakthrough Mental Health Services may access these records without your consent. Both supervisor and Breakthrough Mental Health Services are legally bound to protect your privacy and confidentiality.


Conclusion
By submitting this form, you acknowledge that you have read and understand this informed consent form, our privacy policy (https://www.bmhs.com.my/privacy-policy), terms and conditions (https://www.bmhs.com.my/terms-and-conditions) and agree to participate in therapy services. You also acknowledge that you understand and accept that your therapist's supervisor or authorised staff of Breakthrough Mental Health Services may access your records for quality assurance and supervisory purposes without written consent and the exceptions to confidentiality.

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