Required fields are marked with asterisks (*)

Family Services Durham (FSD) Brief Therapy Report Request Form

Family Services Durham (FSD) follows policies and processes to protect the privacy of client records and allow the release of information to those who are authorized to receive it. Complete this form to request a brief therapy report 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:

A brief therapy report typically includes the date of each attended session, the nature and focus of service, the counselling goal(s), the key therapeutic interventions/modalities used, comments about client-reported progress towards goal(s), and any referrals or recommendations for additional or subsequent supports that were made during service.

FSD does not diagnose, and does not take a position in third party matters (including, but not limited, to, situations involving criminal or family court proceedings, family members, employers or employees, unions, or insurance claims).

If you would like a brief therapy report to be released to a third party (such as a lawyer, insurance company, or other service provider), that third party must submit a request directly to FSD by email, fax, or land mail.

If you request a brief therapy report about someone for whom you are the substitute decision-maker, FSD staff will confirm you have the authority to receive the information prior to preparing/providing the report.

If you request a brief therapy report about service that involved one or more other people, each person (or their substitute decision maker, when applicable) must consent in writing to the release of the report.

Upon receipt of this form, FSD staff will contact you to confirm your request, discuss applicable fees, and discuss requirements to obtain the consent of others who participated in the service if/as required.

When the report has been prepared, you will be required to pick up a hard copy in person. Unless you are receiving it from your current Counsellor during an appointment, you will be required to show a piece of government-issued photo identification when you pick up the report. Therapy reports will not be issued electronically (i.e. via email).

First and last name:

Phone number:

request a brief therapy report pertaining to the participation of the following individual(s) in service at FSD:

First and last name:

Date of birth:

Add Remove

From (date):

to (date):

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

I agree to pay any applicable administration fees before the report is released to me.

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

Before the report 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(s) the information pertains to.

The requested documentation will be prepared 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 for my request to be processed. If FSD anticipates my request cannot be fulfilled within 30 days due to an exceptional circumstance, I will be notified.

After I am advised the report is ready, it will be destroyed if I do not pick it up within 30 days.

I acknowledge FSD is not responsible for the protection of the privacy and confidentiality of the information contained in the report once it is provided to me, and cannot be held liable for any consequences of my choice to remove this information from FSD.

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

Items marked with an asterisk* are required fields.

Enter your first and last name:

Date:

Enter your primary email address:

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), and process your request for a brief therapy report. 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.