Consent To Participate In The Wait List - Cmha Middlesex printable pdf download

Consent To Participate In The Wait List - Cmha Middlesex

Consent to Participate in the Wait List Clinic at

Canadian Mental Health Association, London-Middlesex

I, ____________________________ consent to participate in the Wait List Clinic at the

Canadian Mental Health Association Middlesex (CMHA Middlesex).

I acknowledge that I have read, understand and agree to the conditions and items

outlined below:

1. Records and Documentation

I understand that:

1) My intake information, from the agency from which I was referred, will be

accessed by the Wait List Clinic staff and student volunteer participants in order

to ensure that you meet the requirements of the Wait List Clinic and are

assigned to the most appropriate providers of service.

2) My records from The Wait List Clinic at Canadian Mental Health Association

Middlesex Branch will be kept in locked and secured file cabinets at CMHA

Middlesex. Senior psychology residents and supervising psychologists will be

entering information into the record regarding my counseling sessions.

________ Initials

2. Privacy and Confidentiality

The Wait List Clinic at CMHA Middlesex follows the privacy policy at CMHA Middlesex.

The privacy policy at CMHA Middlesex was explained to me at my assessment and

intake appointment. I am also aware that the privacy policy is available online. I am

aware that the student volunteers and psychologists associated with the Wait List Clinic

are considered to be ‘agents of CMHA” and as such are bound by the privacy and

confidentiality policy of CMHA Middlesex. _________Initials

3. Limits to Confidentiality

I am also aware that there are some important exceptions to confidentiality.

Information may be released without my consent if a member of the staff of The Wait

List Clinic at CMHA Middlesex:

believes you may be a danger to yourself or to others.

Consent To Participate In The Wait List - Cmha Middlesex