July 6, 2020
2:00 pm to 3:30 pmAdd to Calendar (iCal) Add to Google Calendar
By Registering for this online workshop, you consent to the following:
CONSENT FOR ELECTRONIC COMMUNICATION
(Telephone or other secured online platforms)
I understand that my CMHA worker has offered to provide consultation via phone or other electronic communication.
- I authorize my CMHA Worker to allow us to meet via telephone or a secure online service platform. I am aware that there may be additional charges from my internet/telephone provider if I exceed my data or phone minutes while using electronic communication for this service.(Note for a Client: Please check your data / phone limits to ensure you do not incur unexpected overages.)
- My CMHA Worker has explained to me that the technology used will not be the same as a direct, client/worker session due to the fact that I will not be in the same room as my provider.
- I understand that a virtual consultation has potential benefits including easier access to care, continuity of care, and the convenience of meeting from a location of my choosing.
- I understand potential risks to this technology, including interruptions, unauthorized access, and technical difficulties, which cannot be predicted. I understand that my CMHA Worker or I can discontinue the session at any time if it is felt that the electronic connections are not adequate for the situation.
- I understand that the electronic session will not be audio or video recorded at any time, and that we will both disable computer and device-generated recording to the best of our abilities.
- I understand that the limitations to confidentiality outlined in our original Statement of Information Practices and Informed Consent Agreement, applies to the electronic format.
- I understand that it is important to connect from a quiet room, with no interruptions, where my privacy is guaranteed.
- My consent to participate in this electronic service shall remain in effect for the time period we agree upon, which we can modify, or until I revoke my consent either verbally or in writing.
- I agree that there have been no guarantees or assurances made about the results of this service.
I have had a direct conversation with my CMHA Worker, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in language which I understand.
I confirm that I have read and fully understand the above.