Mapagkalinga Intake

Mapagkalinga Intake Form

Start Date*

Full Name*

Birthdate*

Age*

Gender*

Email Address*

Address*

Contact Number*

Religion*

Level of Education*

Occupation*

Marital Status*

Who Lives With You?*

Do you have any previous mental health diagnosis?*

Yes No

Have you been hospitalized for mental health reasons?*

Yes No

Do you use tobacco products?*

Yes No

Do you drink alcohol?*

Yes No

Referred By*

Reason for Refferal*

Appointment Type*

Emergency Contact Name*

Emergency Contact Relation*

Emergency Contact Number*

Over the last two weeks, how often have you been bothered by any of the following problems:

Informed Consent & Data Privacy Notice

In accordance with the Republic Act No. 10173, also known as the Data Privacy Act of 2012 (DPA), we are committed to protecting your personal and sensitive information. By proceeding with this intake form, you acknowledge and agree to the following terms:

1. Collection and Purpose

We collect personal data (name, contact details) and sensitive personal information (health status, mental health history) for the following legitimate purposes:

To facilitate professional clinical assessment and treatment planning.
To maintain accurate medical records and administrative documentation.
Research and Development: Your de-identified or anonymized data may be used for statistical, scientific, or medical research to improve mental health services, ensuring that your individual identity cannot be traced.

2. Rights of the Data Subject

Under the DPA, you are entitled to the following rights:

Right to be Informed: To know if your data is being processed.
Right to Object: To withhold consent to the processing in case of changes to the purpose.
Right to Access and Rectification: To request a copy of your data or correct any inaccuracies.
Right to Erasure or Blocking: To suspend, withdraw, or order the removal of your personal data from our system.

3. Data Protection

We implement reasonable and appropriate organizational, physical, and technical security measures to protect your data against unauthorized access, use, or disclosure. Data will only be retained for as long as necessary to fulfill the purposes outlined above or as required by healthcare regulations.

By clicking "I Accept", you certify that you have read and understood this notice and voluntarily grant your informed consent to the processing of your information as described.

Success!

Thank you for answering the intake form.