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Family Services Durham (FSD) Attendance Letter Request Form

Family Services Durham (FSD) follows policies and processes to protect the privacy of client records and to allow the release of information to those who are authorized to receive it. Complete this form to request an attendance letter pertaining to service that was provided to you (or to someone for whom you are a substitute decision maker).

Please read the following information prior to submitting this form:

An attendance letter states the date of each attended counselling session. It does not include the dates of any sessions scheduled to occur in the future.

An attendance letter does not include any details about service beyond the dates of attended sessions.

An attendance letter will be released to the client who requested it (or their substitute decision-maker, when applicable). Attendance letters are not released directly to third parties.

Letters pertaining to service that involved two or more people will confirm only the requester’s attendance, and will not include information about any other participant. If other file member(s) also want an attendance letter, they (or their substitute decision‑maker, where applicable) must submit a separate request form.

Upon receipt of this form, FSD staff will contact you to confirm your request, confirm your identity and/or authority to receive the letter (if/as required), and make arrangements to provide you with the attendance letter.

Your first and last name:

Your phone number:

request a letter confirming the following individual's attendance in counselling at FSD:

First and last name:

Date of birth:

Address:

I want confirmation of attendance for (choose one):

all service the person named above has received from FSD.

service the person named above received from FSD during the following timeframe:

I would like to receive the letter in the following way (choose one):

I will pick it up at FSD.

send it to me via email - enter email address below:

send it to me via land mail - enter complete mailing address below:

By submitting this request, I authorize the release of information as described above and confirm I understand and agree to the following:

Before the attendance letter is released to me, I may need to provide proof of identity by showing a piece of government-issued photo identification.

Before the attendance letter is released to me, I may need to provide proof of my authority to receive this information as a substitute decision maker (i.e. proof of guardianship, legal sole decision-making responsibility, power of attorney) for the person the information pertains to.

The attendance letter will be released by an FSD staff who is a licensed mental health practitioner. This may not be the same person who provided the service the information pertains to.

It may take up to 30 days to process my request. If FSD anticipates my request cannot be processed within 30 days due to an exceptional circumstance, I will be notified.

If I request a hard copy for pick up and have not picked it up within 30 days, it will be destroyed.

I acknowledge FSD is not responsible for the protection of the privacy and confidentiality of the attendance letter once it is provided to me, and cannot be held liable for any consequences of my choice to consent to the removal of this information from FSD.

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

Enter your first and last name:

Date:

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

Family Services Durham (FSD) collects your personal information under the authority of the Personal Health Information Protection Act (PHIPA) and other applicable legislation. The information you provide will be used solely to verify your identity, confirm your authority (if applicable) to receive the information you are requesting, and process your request. By submitting this form, you consent to the collection, use, and disclosure of your personal information for these purposes. For questions about this collection, contact the Region of Durham's Access and Privacy Office at privacy@durham.ca.