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Family Services Durham - Client Consent for a Support Person

I, (enter your first and last name - required)

consent to the attendance of the person/agency identified below as a support person during my counselling session(s) at Family Services Durham.

I consent to the sharing of any information related to me that is disclosed to this person through discussions and any other counselling activities during my session(s) for the purpose of them providing me with this support.

By signing this consent to release information, I confirm I understand and agree to the following:

My support person’s role during the session(s) they attend is solely to provide me with support, and they will not be receiving counselling/psychotherapy or other service from FSD during my session(s).
FSD is not responsible for any situations where my support person may disclose to others information I share during the session(s) they attend.
If my support person is assisting with a language barrier, FSD is not responsible for the accuracy of the information they convey.

I fully understand the nature and purpose of this consent and am giving my consent and authorization voluntarily.

I understand that this consent may be withdrawn at any time by me or by Family Services Durham and that withdrawal of consent is not retroactive and may be subject to exceptions. I understand that unless revoked, this consent will remain effective for one (1) year from the date of signing.

By signing below, I acknowledge I have read and understood the above and acknowledge that if signing on behalf of a minor or incapable person I have the authority to do so.

Enter your first and last name (required):

Date (required):

Enter your primary email address (required only if signing electronically):

I acknowledge that checking this box has the same force and effect as signing the document in person (required only if signing electronically):

Agree

Add your signature:

Clear

Personal information contained on this form is collected pursuant to the Municipal Act 2001, and in accordance with the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). Personal information on this form will be used to assist Family Services Durham in determining eligibility and approval for counselling and may be subject to disclosure under the MFIPPA if circumstances warrant. Questions regarding the collection, use and disclosure of personal information should be directed to the Corporate Privacy Office at foi@durham.ca, 905-668-7711 ext. 2204 or 1-800-372-1102.

If you require this information in an accessible format, please contact Family Services Durham at 905-668-7711 ext 2709.