CLIENT CONSENT FORM

Confidentiality and limits of confidentiality

Generally, information shared during the provision of services by Golden Sun Wellness and Counselling (GSWC) is considered to be your confidential personal health information and falls under the Personal Health Information Protection Act (PHIPA). Because of that this information will not be shared without your consent, except where required by law.

Your personal health information gathered over the course of receiving the services at GSWC will be shared among GSWC employees for the purposes of administration (scheduling, payment of fees, etc.) and/or provision of health services (psychotherapy, assessment, consultation, etc.).

Mandatory reporting

Law requires that confidentiality be broken to a necessary extent under the following circumstances:

• When it is believed that you are at imminent risk of seriously harming yourself or another person.
• When there is a suspicion that a child (a person under 18 years of age) is at risk of being abused or neglected.
• When there is a suspicion that an elder in a long-term care home or a retirement residence is being abused or neglected.
• When you disclose that you have been sexually abused by a registered health care professional.
• When your counselling record is subpoenaed by a court of law or is requested under a police warrant.
• When a relevant professional college conducts an audit of records to ensure the records are appropriately kept.
• When consulting with professionals outside of GSWC who are not within your circle of care (in such situations your identifying details, e.g. your name, will not be mentioned).

Third party payers (insurance companies and WSIB)

When you are paying for GSWC services through insurance or benefits, insurance companies can request information from GSWC for the purposes of administering the benefits plan. Typically, this information includes the client’s and the provider’s name and license number, the type and duration of service, date, and fees paid. Very rarely, they may request more detailed information, such as a summary letter or case notes. GSWC will not provide this information to a third party without your explicit consent. You have a right to refuse that GSWC provides such information, however, the third party has the right to refuse benefits, or take any other action in accordance with their own policies and the law.

If you receive services under the Community Mental Health program of Workplace Safety and Insurance Board (WSIB) additional limitations to confidentiality apply. Any information shared over the course of assessment and/or treatment that is relevant to your WSIB case will be communicated to WSIB. Please be aware that reports prepared for WSIB may also be shared with your employer under specific circumstances as permitted by law.

Benefits and risks of services offered at GSWC

GSWC offers a variety of services, such as counselling, psychotherapy, psychological assessment, and other services. All of them are a mutual effort between the client and their provider. Agreement on goals, on ways in which those goals are achieved, and mutual respect are some of the most important things in positive outcomes. Although these various services have many benefits, some of them may also result in unpleasant emotions, such as sadness or anger. Services offered at GSWC are a voluntary activity, and you are not obligated or forced to do things that do not feel right to you. If you feel that way, it is a good idea to discuss this with your provider immediately. You can also withdraw from GSWC services at any time without penalty.

Telehealth services

GSWC telehealth services are offered through the Owl Practice software and occur primarily through video. Occasionally, telephone conversations can be used as a backup means of contact, such as when there are wi-fi issues.

For telehealth services specifically, you need to have a private space located in the province of Ontario for the session to proceed. If you join from a public or outdoors space (e.g., a coffee shop, a national park, a sidewalk), while being in a situation that is not suited for therapy (e.g., while driving a car), while in the presence of other people, or joining from somewhere other than Ontario (e.g., from Buffalo, NY) – the session will be immediately terminated and considered a late reschedule.

Risks specific to online counselling

GSWC uses record management and videocall software that is compliant with PHIPA, employs cyberprotection software services, and takes all reasonable steps to protect the security and confidentiality of your information. Despite that, online communication involves some inherent risks of information being intercepted or unintentionally disclosed in some other way.

If at the time of your session you are connected to a public wi-fi network, such as at a hotel, please use a Virtual Private Network (VPN) service to add additional layer of protection to your information.

Creating your account

You will need an email address for your account with GSWC. Please ensure that you are the only person with the access to your email. If you share your email with someone else, please immediately inform your provider.

Recording

Healthcare providers are not legally allowed to record the sessions without your explicit, written consent. We ask that you extend the same courtesy to us and do not record GSWC sessions by video or audio, by taking pictures, or in some other way without asking for your provider’s consent. Secretly recording sessions is likely to damage the therapeutic alliance and may lead to the termination of services at GSWC.

Between session availability

We are not available to provide counselling services at times other than your scheduled sessions. GSWC does not offer crisis or walk-in services. During our sessions we may negotiate a safety plan for you to follow during emergencies or crises. In the event of an emergency or a crisis, such as experiencing suicidal thoughts, you can use the following resources:

• National Suicide Prevention Line: 1-833-456-4566
• Wellness Together Canada: https://www.wellnesstogether.ca/en-CA
• Crisis and Mental Wellness Centre: 736-744 Ouellette Avenue (8am-8pm, 7 days a week) in Windsor, ON, N9A 1E1
• Community Crisis Centre: 519-973-4435 in the Windsor-Essex Area
• Distress Centres of Greater Toronto: 416-408-4357 in the GTA
• Call 911 or go to your local hospital’s Emergency Department

Communication Policy

Emailing. GSWC limits email communications to the first contact, and after that, to scheduling or rescheduling appointments. As much as you can, please avoid sharing personal health information by email as it is not secure enough.

Phone calls. Please call GSWC for matters that can be handled in a brief amount of time (e.g. rescheduling or telling your provider that you are running late). Messages (voicemail and email) are checked 8am to 1pm, Monday to Friday. Please expect 24-48 hours for a reply.

Texting. In some circumstances, such as when you arrive at location, you can text your provider to let them know you arrived. Your provider will then text you back to invite you in. We do not read, reply, or send texts in other circumstances.

Owl Practice secure chat. The Owl Practice system allows to exchange encrypted chat messages. We use this function occasionally instead of an email. There are no “live” chat sessions, so if we set up a chat, please expect a delay in response. Please do not use it for exchange of urgent information (such as suicidality) or as a way to have a telehealth session.

Sending files. If you need to send your provider a file or a document, please use the Owl Practice system or fax to do so. Both platforms meet PHIPA standards for the security of information.

Social media. Members of GSWC will not knowingly accept a “friend” request, or communicate via instant messaging, “chatting”, or similar technologies (e.g., on Facebook) with current clients. In some instances, we may be ethically obligated to keep applying this policy even after services at GSWC are concluded.

Retention of records

Your personal health data will be stored for a period of 10 years, after which it will be destroyed.

When you are no longer a GSWC client

You can choose to end receiving services by notifying GSWC that you do not wish to receive further services at any time. There is no penalty for that, although the rules for late cancellations and no shows still apply. You can request a referral to a different provider if you wish.

You can also withdraw from the services at GSWC. What this means is that you do not show up or cancel and not reschedule your appointment, and you do not communicate with GSWC over a period of 60 days. In such event it is agreed that you withdrew from the service and are no longer a GSWC client.

Please keep in mind that if you do not show to your appointment or cancel and not reschedule, we will respect your autonomy and it is up to you to reach out to GSWC.

Under exceptional circumstances, GSWC may stop offering you services without citing a reason. In such event we will make every reasonable effort to provide an arrangement for alternative services elsewhere.