ASWW New Client Registration

ASWW New Client Registration
Welcome to the Alzheimer Society Waterloo Wellington (ASWW)! We support individuals living with mild cognitive impairment or dementia and their care partners.

To help us in supporting you, please complete our registration form so that we can create a confidential client file to document your involvement with us and important information about your journey with mild cognitive impairment/dementia.

Just like at a doctor’s office, as part of the health care system, the Alzheimer Society collects personal health information from you such as your date of birth and OHIP number to identify you and to provide you the best possible care. For example, the OHIP number helps us to communicate with other organizations who are a part of your care team and helps us as an organization to understand the impact of the support we provide. Like all information collected, we protect your privacy and confidentiality. Our privacy information is attached to this form for you to read, and if you wish, we can connect you with the Alzheimer Society Privacy officer for any questions you may have for how we protect your information.
We require a completed form for each individual who wishes to access services from us. Care partners are required to complete a form with their information to meet with a team member.
I am filling this form out for myself:*

YesNo - I am filling this form out on behalf of the person named below. Please note all information provided is about the person you are filling the form out for. Please ensure that you have the person's consent to complete the form on their behalf.
Name of Person who wants to be Registered with ASWW:*

First NameLast Name
The person the form is being filled out for is a:*

Person who is living with cognitive impairment and/or dementiaPerson who is supporting someone who is living with cognitive impairment and/or dementia
Phone Number*
Please enter a valid phone number.
Do we have permission to call you by phone?*

YesNo
Do we have permission to leave a voicemail?*

YesNo
Date of Birth

MonthDayYear
Date
Health Card Number and Version Code - required by the Ministry of Health which funds our Programs & Services*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ASWW exists to primarily serve residents residing in the geographic area of Waterloo Wellington. Please email support@alzheimerww.ca to provide more information.
Do we have permission to send you mail to this address?*

YesNo
Email
example@example.com
Preferred Language to receive services*
Languages Spoken
I confirm consent to receive electronic communications about ASWW programs, events, volunteer opportunities, and other service information.*

YesNo
Why are we collecting demographic data?
To ensure healthcare responds to the individual needs of people living with dementia and their care partners.

To improve the healthcare quality provided to those affected by dementia (equity is a component of quality).

To ensure Alzheimer Society services reach the entire community affected by dementia.

To determine the composition of Alzheimer Society service recipients and to customize program and service delivery and to remove barriers accordingly.

To support the activities of seeking out and responding to funding and partnership opportunities and requirements intended to increase the provision of equitable care.
Gender*

FemaleMaleIntersexNon-binaryTransTwo-SpiritPrefer not to answerNot listed
Ethnic Group*

BlackCaucasianEast AsianHispanic or LatinoIndigenousSouth AsianSoutheast AsianWest Asian or ArabMixed RacePrefer not to answerOther
Community*

UrbanRuralMixed Urban/RuralPrefer not to answerI do not know
Orientation*

BisexualGayLesbianHeterosexualQueerTwo-SpiritNot listedPrefer not to answerI do not know
Income*

Less than $25,000$25,000 - $49,999$50,000 - $99,999$100,000 - $149,999More than $150,000I prefer not to answer
Health Status*

Behavioural disorderChronic illnessDevelopmental disabilityLearning disabilityPhysical disabilitySensory disabilityDrug or alcohol dependentEmotional health disorderPrefer not to answerNoneI do not knowOther

Our Privacy Practices
Our Privacy Practices

A guide to understanding how your information is collected, kept, and shared.
YOUR INFORMATION AND RECORDS

The staff of the Alzheimer Society Waterloo Wellington (ASWW) are required to keep records of the services we provide and the conversations that we have with you. We refer to these notes so we can recall information to best support you.

A law passed by the Ontario government in 2004 called Personal Health Information Protection Act gives health care providers rules to follow for handling the information we record about you, which is called personal health information.

In addition, staff, professional placement students, and volunteers of ASWW all sign confidentiality agreements prior to beginning their work.

SHARING YOUR INFORMATION WITHOUT PERMISSION

There are circumstances in which staff members are legally allowed (and may be legally required) to share your personal health information without your permission.

These circumstances include

1. Medical emergencies

2. Situations which staff are served with a search warrant or subpoena requiring release of your information to legal authorities.

3. Staff may also share your personal health information if the information you provide gives them reasonable grounds to suspect that you will harm yourself or situations of abuse has occured.

YOUR RIGHTS

Under the Personal Health Information Protection Act (PHIPA) you have the following rights:
- To see and correct your information on file with ASWW
- To make a complaint about the handling of your personal information by ASWW
YOUR CIRCLE OF CARE

Your health information may be shared with, or collected from, members of your circle of care. The "cirlce of care" refers to individuals and organizations who provide services to you. This may include doctors, hospitals, Ontario Health at Home and day program providers.

You may tell us that you can do not want us to share information with certain members of your circle of care. We require your permission (verbal or written) to share your personal information with any person or organization outside your circle of care.

PROTECTING YOUR INFORMATION

Your health information will only be collected, used, and shared for the purpose of meeting your health and service needs. This information will be accessed by only the relevant staff, professional placement students, and trained volunteers of ASWW who are providing services to you.

Information collected about you is stored in a secure computer database indefinitely. ASWW also has a privacy policy to protect the confidentiality of your information, which you are welcome to review.

Demographic and statistical information will also be used by ASWW for service planning and management.

COMPLAINTS

You may contact the privacy officer for ASWW for more information or to make a complaint. You can do so by contacting our offices.

You may also forward complaints about the handling of your information to the Information and Privacy Commissioner of Ontario (IPC).

The IPC can be reached by the following methods:

MAIL

1400-2 Bloor Street East, Toronto, Ontario M4W 1A8

PHONE

1-800-387-0073

WEBSITE

www.ipc.on.ca

Terms of Service - Please Read and Consent
TERMS OF SERVICE

Updated January 2024
The Alzheimer Society Waterloo Wellington’s (ASWW) role is to support persons living with dementia/cognitive impairments and their care partners in living well with a dementia/cognitive impairment diagnosis. Our programs and services include support and education groups, counselling, care coordination, and social/recreational opportunities. These programs may be offered in-person, by phone, or virtually through email or video conferencing. Please note that we are using online technology that helps us connect with you. Privacy measures put in place by these technologies will protect your privacy. Despite reasonable efforts to safeguard the confidentiality and security of electronic and virtual communications, it is only possible to partially secure the information.

Our programs help people remain supported and engaged throughout the dementia/cognitive impairment journey. Some French language services are available upon request.

All personal information is protected by confidentiality. A confidential file will be created by a Registered Social Worker (RSW) or a supervised Social Work intern during your initial intake appointment. We will securely keep your file in our electronic database per the Personal Health Information Protection Act, 2004 (PHIPA). All paper records will be held for at least 10 years for staff to refer to.

Information we keep on file may include the following:
- The services you receive from us and the dates we provided them to you
- Demographic and statistical data
- Information about you and your situation is necessary to understand your service needs
ASWW operates as a team where all staff and student interns are ethically bound by confidentiality. Information is only shared where it is found to be clinically necessary and helpful in providing service to you.

Your health information may be shared with or collected from your ‘circle of care.’ The circle of care refers to individuals and organizations who provide services to you. This may include: doctors, hospitals, Ontario Health at Home, day program providers, and community support services. You can tell us if you do not want us to share information with certain members of your circle. You may also permit us, verbally or in writing, to share your personal information with any individual or organization outside of your circle of care.

Exceptions to confidentiality in which staff members must report or are required to share your personal health information without your permission include some of the following examples:
1. Medical emergencies
2. Court-order
3. If we believe you or someone you know is at risk of or experiencing harm to self or others
4. If a child under the age of 16 could be at risk
5. Professional misconduct in the form of abuse or behaviour that has placed you or someone you know at risk
One can discuss questions or concerns about our Terms of Service with an ASWW staff member. Alternatively, you may contact our office and request to speak with ASWW’s privacy officer for more information or to make a complaint by contacting Michelle Martin by email: mmartin@alzheimerww.ca or by calling our offices, ext. 2014. You may also forward complaints about ASWW’s handling of your information to the Information and Privacy Commissioner of Ontario: by phone (1-800-387-0073); or by mail (1400-2 Bloor Street East, Toronto, Ontario, M4W 1A8).

The Alzheimer Society Waterloo Wellington strives to provide a safe setting for all. Violent, aggressive, threatening, or disruptive conduct is not permitted. Verbal or physical abuse of our staff or volunteers will not be tolerated. Thank you for your cooperation!

At the Alzheimer Society Waterloo Wellington, we welcome people of any age, ability, gender identity and expression, race, colour and sexual orientation.
I have read and consent to the Alzheimer Society Waterloo Wellington Terms of Service.*

YesNo - Please note if you do not consent to ASWW terms of service we will not be able to open a file for you. Your access to our programs and services will be limited to general education.
Terms of Service- Electronic Email Communication
The Alzheimer Society of Waterloo Wellington (ASWW) offers clients the opportunity to communicate through the use of electronic email communications. ASWW will use reasonable means to protect the security and confidentiality of electronic information sent and received. However, because of the risks outlined below, ASWW cannot guarantee the security and confidentiality of electronic email communication and will not be liable for improper disclosure of confidential information that is not the direct result of intentional misconduct by ASWW.

The risks of electronic email communications include, but are not limited to, the following:
- The privacy and security of electronic email communication cannot be guaranteed
- Employers and online services may have a legal right to inspect and keep emails that pass through their system
- Email is easier to falsify than handwritten or signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email once it has been sent
- Emails can introduce viruses into a computer system, and potentially damage or disrupt the computer
- Electronic email communications can be forwarded, intercepted, circulated, stored or even changed without the knowledge or permission of the physician or the patient. Email senders can easily misaddress an email, resulting in it being sent to many unintended and unknown recipients
- Email is indelible. Even after the sender and recipient have deleted their copies of the email, back-up copies may exist on a computer or in cyberspace
- Use of email to discuss sensitive information can increase the risk of such information being disclosed to third parties
- Email can be used as evidence in court
- Despite reasonable efforts to protect the privacy and security of electronic email communications, it is not possible to completely secure the information
- Email communication is considered part of the clinical record. Copies of emails between client and ASWW staff may be attached into client file
- Information provided by client via email is subject to Exceptions to Confidentiality as outlined in ASWW Terms of Service
By providing ASWW with my email address, implicitly I agree to the use of my email for the purpose of electronic communications with ASWW.

Please note, that this document is in addition to the Terms of Service found in the Alzheimer Society of Waterloo Wellington Program Guide and/or the other side of this document.

Questions or concerns about our Electronic Email Communication terms of service can be discussed with an ASWW staff member. Alternatively, you may contact our office and request to speak with the ASWW’s Privacy Officer for more information or to make a complaint. You may also forward complaints about ASWW’s handling of your information to the Information and Privacy Commissioner of Ontario: by phone (1-800-387-0073); or by mail (1400-2 Bloor Street East, Toronto, Ontario, M4W 1A8).
I have read and consent to the Alzheimer Society Waterloo Wellington Terms of Service - Electronic Communication*

YesNo
Client Signature*

Clear
Date*

MonthDayYear
Date
Consent provided by POA - Name:
Date

MonthDayYear
Date
Relationship:
POA Signature

Clear

ASWW New Client Registration

Why are we collecting demographic data?

Our Privacy Practices

TERMS OF SERVICE

Terms of Service- Electronic Email Communication

Learn More About Our Programs and Services