Consent Privacy

Consent, Privacy and Confidentiality Form

    I, , hereby acknowledge that Well With My Soul Counselling Services has advised me of the following:

    • Well With My Soul Counselling Services’ Privacy and Confidentiality Policy and Records Management Policy and File Access Procedure. These policies are set forth on the website and are downloadable.

    • My right to access personal information.

    • My right to withdraw my consent at any time.

    I am aware of, and understand that, Well With My Soul Counselling Services may need to collect and disclose personal information to third parties (as required) to provide an improved level of care.

    Consent

    Please select one option:




    Name of counsellor


    Signature