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Ontario Heroes Clinician Consultation Form
www.ontarioheroes.ca
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Ontario Heroes Health and social services is a group of volunteers striving to empower and support diverse communities across Ontario in reaching their full potential and equal participation in the community. we strive to create a culture of volunteer engagement where volunteers find meaningful ways to support Canadians.
Informed Consent
*
Consent obtained/received from client/applicant to collect, use and disclose his/her Personal/Health information within circle of care for virtual/telephone consultation, Counseling, Referrals, Linkages, System navigation and Care coordination.
Name of the service user
*
Your answer
Area of service provided
Individual Counseling
Family Counsling
Short-term Case management
Referral / Linkages
Repatriation
Career guidance / Mentorship / Job Links
Housing Support
System Navigation and Care Coordination
Data
Your answer
Action
Your answer
Response
Your answer
Evaluation:
Your answer
Volunteer/Consultant/Case worker name:
*
Your answer
Date
MM
/
DD
/
YYYY
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