Consent to Mental Health Services Form

Consent to Mental Health Service

We are committed to protecting the privacy of your personal information and have developed practices to comply with legislation. The information you provide is private and confidential, within your treatment of the medical practice. Notes are a part of your medical record and are accessible to your Medical and/or Allied Providers of the Family Health Team.  If there is any information that you would not like reflected in the notes, please discuss this at the onset of counselling. If you have questions about your personal information, please ask your mental health service provider.

Confidentiality is respected at all times. No information will be communicated, directly or indirectly to a third party outside of the Portage Medical Family Health Team without the client’s informed and written consent.

Exceptions to confidentiality include legal and/or ethical obligations:

  • Child (16 and under) or dependent abuse or neglect
  • Clear and imminent danger to self-and/or others
  • A court order to release a client’s file
  • Consent by client to provide information to an insurance company
  • Report a health professional who has abused a patient
  • Share information with a clinical supervisor and/or regulatory college for supervision, auditing    and/or complaint purposes.

You have the right to request to see any personal information that has been collected about you or your situation throughout the course of mental health service provision.

Terms of Counselling:

Portage Medical Family Health Team provides short-term counselling and most clients report change within 8-10 sessions.

Your counselling file will be considered closed when:

  • Counselling is concluded.
  • You cancel with less than 24 hours’ notice or miss two (2) consecutive appointments.

To resume counselling, if your file has been closed for a duration of 6 months, you may self-refer by contacting the Portage Medical Family Health Team at 905-354-9393, ext. 1.

Maintaining your scheduled appointment is important to your counselling treatment plan, in addition to ensuring service to other clients.  As such, please provide 24 hours’ notice in the event that you must cancel your appointment.

As your appointment time is reserved for you, we expect clients to attend appointments on time as scheduled.

Our Family Health Team office hours are Monday 12:00 pm to 8:00pm and Tuesday to Friday 8:30-4:30. Although every attempt is made to respond to the needs of current clients, 24-hour coverage and/or emergency counselling services are not provided.  If you are in crisis please contact one or more of the following:

Mental Health & Addictions Access Line 1-866-550-5205 (#1-COAST, #2-Mental Health and Addictions)

Pathstone Mental Health Crisis Service 1-800-263-4944 (Under 18 years of age)

Your Life Counts

Maintaining a workplace environment free from harassment or verbal abuse is important to the providers at the Portage Medical Family Health Team and legislated by the Occupational Health and Safety Amendment Act.  Therefore, harassment or verbal abuse will not be tolerated and will be cause for termination of services.

 Consent to Service:

I/We                                                                            have reviewed this document in its entirety and have had the opportunity to express any concerns and have any questions answered to my/our satisfaction.  Further, I/we understand and consent to the above counselling conditions and indicate this with my/our signature below:

Client Signature:                                                                  Date: 
Client Signature:                                                                  Date: 
Counsellor’s Signature:                                  ______     Date:                                         

click to download  Consent to Mental Health Services