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Format: (000) 000-0000.
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- Have you ever received mental health or peer support before?*
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- Availability*
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- Communication Preferences*
- Do you have access to a device that can support Zoom or Google Meet?*
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- Service Agreement understand: My peer support worker and I both have the right to be treated with respect and without judgment regardless of our gender, race, class, immigration status, culture, health condition, disability, sexuality, etc. Our sessions together will last approximately 50 minutes and will take place at agreed dates and times. It is important to be on time for my virtual drop-in session and be in a private space. If I am unable to attend a session, I will provide at least 12 hours' notice. I am responsible for rescheduling a missed session. If I miss 2 appointments without providing at least 12-hr notice my services may be closed. If I cancel 3 appointments with proper notice my services may be closed. My peer support worker is only available to support me during our scheduled sessions. Emails are only used for scheduling appointments and information sharing. Please note that our regular business hours are from 8.30 am to 4:30 am, Monday to Thursday, not including statutory holidays. My peer support worker may document brief notes in confidential client database regarding any contact that we have with one another and any contact they have with other agencies or individuals. My peer support worker may discuss my file with their supervisor, their external clinical supervisor, or other staff members who are also required to keep this information confidential. I agree to maintain the confidentiality of any clients or volunteers that I may encounter at bookmytherapy. I understand that confidential services mean that the release of any information regarding my involvement with bookmytherapy may only occur with my written and signed consent. There are limited exceptions to confidentiality that include: If I am at risk of inflicting serious physical harm on myself or another individual. If there are any unreported cases of suspected child abuse or neglect or incidents of children witnessing violence where there is an ongoing risk. If there are known or potential incidences where a Regulated Health Professional has abused a client. If information is subpoenaed by the Courts. My peer support worker will make their best effort to inform me prior to any reporting, and if possible, I will be present at the time the call is made.*
- Personal Health Information Consent: I understand that my personal health information (PHI) is collected to provide safe and effective peer support and to support educational purposes within bookmytherapy. I understand that: I have the right to withdraw or modify my consent to the collection, use, or disclosure of my PHI at any time. - I may ask questions before, during, or after any session to clarify how my information is being collected or used. I am not required to share information I do not wish to disclose; however, withholding information necessary to ensure my safety may result in being unable to participate in the teaching clinic. - My PHI will remain confidential and will not be shared outside bookmytherapy unless required by law. By checking the box, I confirm that I have read and understood the above information, and I give my informed consent for the collection and use of my personal health information. *
- Privacy and Sharing of Information Consent: I authorize bookmytherapy its associated staff to collect my personal information. I understand that my personal information is confidential and will only be disclosed to third parties with my permission. *
- Client Agreement / Appointments Consent: Appointments: • Peer support will be provided by Students who are enrolled in the social work program; they are not Registered Social Worker and services (if chargeable) may not be reimbursed by health plans. • Appointments are up to 50 minutes in length and may include up to 20 minutes of intale assessment or as required to ensure support. bookmytherapy reserves full authority to book, reschedule, cancel, discharge, or ban any client at its discretion, with or without stated reason. Information about your role as a client: • Communication between peer support worker and clients during the treatment will be respectful of a quiet and private environment and all cell phones will be adjusted to a quiet setting. • If you happen to be a friend or family member, peer support program will not be permitted due to conflict of interest. All potential conflicts of interest should be declared prior to treatment. • The client will not ask the peer support worker to forgo assessment, consent, or any other treatment protocols that they is required to follow. As a client / patient I understand and agree with the following: • There is a zero tolerance policy for harassment of any staff at any time. • Any sexual or other inappropriate remarks or gestures by the client, even subtle, will result in immediate cancellation of the treatment and denied access to bookmytherapy’s services • Any concerns or complains should be directed immediately to the Director, bookmytherapy in writing. I may withdraw this consent at any time. I have read and understand this Client Agreement Form and I agree to adhere and support these policies, as is my role as a client at bookmytherapy. I also acknowledge that my treatments provided at bookmytherapy will not be performed by a licensed mental health practitione, but by student enrolled in the Social Work program. *
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