The ILC CONFIDENTIAL Client Navigation/Wellness Support Form
Overview
The ILC Foundation provides Peer Wellness Support Sessions to our registered members (completion of the form below will complete your registration). The ILC Foundation Member Benefit Support Program is to provide educational resources to help individuals create a balance between school, work, self-care and leisure activities. We know that living with Ehlers-Danlos Syndromes, its related conditions including chronic pain or other Heritable Connective Tissue Disorders can be isolating and difficult to manage.
These resources are meant to assist members in their self-advocacy needs for access to care for themselves or for family members they care for. These sessions are provided free of charge and are CONFIDENTIAL.
Our 60 minutes sessions (up to a 90 minutes maximum) are offered with an Occupational Therapy Student and a Client Navigator (Wellness Session Leader) as part of a joint educational program with McMaster University Occupational Therapy Program .


Sign in to Google to save your progress. Learn more
What is your name? (First and Last names please) *
Preferred Pronouns *
Please provide your email address:  *
Please provide your phone number for us to contact you to complete the intake questions. *
Preference Meeting Method (select):
*
What would you like to speak about in your Wellness Session?
*
PRIVACY POLICY:
The ILC Charitable Foundation is responsible for the information it holds regarding clients. Staff and volunteers at The ILC must respect and work within organizational policies regarding confidentiality and privacy, consent, and release of information as well as the Personal Health Information and Privacy Act (PHIPA).
PROCEDURES
The ILC works within a team model where a variety of skilled staff, students and volunteers are part of providing high quality services to clients. Clients are informed that this means information may be shared among staff and wellness-support volunteers involved in their care in order to provide the best service possible.
1. At intake, a Wellness-support volunteer or an OT Student will contact you to complete the intake process. They will also confirm that the Client understand this model of care, and that from time to time, there may be Coop Students in observer-ship positions sitting in on the call.
2. Wellness-support volunteers will only collect information that is necessary to provide good service to clients and community and to meet legal and funding obligations. All necessary steps will be taken to ensure that information is accurate, complete, and up to date.
3. All clients are asked to register as members of The ILC. Personally- identifying information is only collected with consent as it pertains to the types of needs and services required. All of the information collected will be recorded with access restricted with the information being housed in a paper file in a locked filing cabinet.
4. Clients are informed of the reasons for the collection, use and disclosure of their personal health information, and their express consent will be obtained if required. (See Informed Consent Policy)
5. Personal information will not be used or disclosed for purposes other than those for which it was collected except with the client’s consent or as required by law. Personal information will be retained only as long as 
 necessary for the fulfillment of those purposes. Client records will be stored and then be shredded following completion of services.
6. Clients have the right to
• Access a copy of their information for their review
• Request a correction of information
• Have assistance in interpreting their record
• Obtain a copy of their record
7. Assistance in understanding the record will be the responsibility of the
primary provider. Should the provider believe that releasing the information could be harmful to the client, the team will be consulted prior to the release. Staff will respond to a request to access a copy of a record for review within 30 days.
8. No client care information is shared with external agencies or practitioners unless an authorized release of information has been obtained. (A client who has agreed to be seen by a specialist will have implied consent to have their medical information transferred to the specialist) Upon receipt of an authorized release of information, staff and/or volunteers must ensure that the client (or guardian) has signed and dated the request, and that the signature has been witnessed. Only the specific information requested is forwarded.
PRIVACY OFFICER
The Executive Director has been appointed Privacy Officer. Clients who have questions or concerns/complaints about The ILC privacy practices are invited to contact the Privacy Officer. They may also contact their provincial Privacy Commissioner.  
*
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy