Consent To Participate In The Wait List - Cmha Middlesex (Page 3 of 4) in pdf

6. Research

By participating in The Wait List Clinic at CMHA Middlesex, I am aware that non-

identifying information about my visits, such as my rate of attendance and demographic

variables, will be collected for research purposes.

I also understand that I will be asked to complete questionnaires about my care at The

Wait List Clinic at CMHA Middlesex. My participation in this research is voluntary, and

my decision to participate or not participate in completing these forms will not affect

my service at The Wait List Clinic at CMHA Middlesex. _______Initials

7. Termination of Counseling Sessions

I am aware that should I be offered the service for which I am waiting during the course

of my counseling sessions with the Student Wait List Clinic, the Wait List Clinic will be

informed and my counseling sessions with the Student Wait List Clinic at CMHA

Middlesex will end. I understand that one or two additional sessions will occur after this

notification to ease with the transition. The service for which I am waiting will receive,

at their request, a summary of the contacts at the Wait List Clinic and suggestions about

my follow-up care. I am also aware that my participation in the Wait List Clinic will not

impact the normal process of accessing the service for which I am waiting in that it will

neither accelerate nor impede my access to the program. If I decline the service for

which I am waiting, I will no longer be eligible to continue to participate in the Wait List

Clinic. _______Initials

8. Crises Between Sessions

I understand that the Wait List Clinic at CMHA Middlesex operates only on Monday and

Tuesday evenings. Therefore, the clinic staff are not available during the rest of the

week if service between sessions is required. It is expected that if I need attention for

urgent matters, I will seek consultation from the agency from which I am awaiting

services and/or access urgent mental health services, such as the Mental Health and

Addictions Crisis Service at 648 Huron Street in London, the London Mental Health Crisis

Service at 519-433-2023 or the Emergency Department at Victoria Hospital.

_______Initials

9. Communication Between The Wait List Clinic and Referring Agency

In order to promote coordinated care, it is important for the Wait List Clinic and the

referring agency to have contact with each other. I consent to the referral source,

__________________________________________, sharing information with the Wait

List Clinic, and the Wait List Clinic sharing information with the referral source, that is

relevant to my referral and care needs for the duration of my involvement with the Wait

List Clinic.

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