I agree to have my child undergo Christian Cognitive Behavior Therapy with Dr. Raissa Paje-Bayawa through online Zoom sessions. I am aware of the limitation of the online platform.

I give my consent to Dr. Paje-Bayawa to discuss in a professional way details about my concerns to my attending psychiatrist/physician should the need for collaboration between them arise.

I understand that although I can send a message to Dr. Paje-Bayawa’s cellphone number, Viber number or Facebook messenger anytime, she will only reply to me when she is available. Given that, her accountability to me and my child ends after our online session and anything that happens thereafter is my/our family’s responsibility.

I understand and agree that in case of emergencies (such as panic attacks, difficulty of breathing, chest pains, and other worrisome physical symptoms, as well as thoughts of hurting others, suicidal attempt or active suicidal ideations, etc), I, being the parent, or our appointed legal guardian will be responsible in bringing my child to the emergency room. Dr. Paje-Bayawa will not be liable during such situations.

I hereby waive any and all rights to claim or institute all actions against Dr. Raissa Paje-Bayawa for any issue arising from the professional engagement.

I am aware that the details I provided are confidential and will only be used for reference. My name and digital signature are attached herewith.