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Psych Treat Consent

The document authorizes psychological treatment services for a worker through the Workers' Compensation Board (WCB). It outlines several key points of consent: [1] the client may decline treatment at any time; [2] treatment success is not guaranteed; [3] referrals may be provided if additional services are needed beyond WCB support; [4] recording devices require consent; [5] reports will be sent to WCB summarizing treatment goals and progress; and [6] information may be used for research to improve WCB services. The client declares understanding and agreement by signing, with witness. Information is protected under privacy acts and collected under the Workers' Compensation Act.

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Dawn Casuncad
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91 views1 page

Psych Treat Consent

The document authorizes psychological treatment services for a worker through the Workers' Compensation Board (WCB). It outlines several key points of consent: [1] the client may decline treatment at any time; [2] treatment success is not guaranteed; [3] referrals may be provided if additional services are needed beyond WCB support; [4] recording devices require consent; [5] reports will be sent to WCB summarizing treatment goals and progress; and [6] information may be used for research to improve WCB services. The client declares understanding and agreement by signing, with witness. Information is protected under privacy acts and collected under the Workers' Compensation Act.

Uploaded by

Dawn Casuncad
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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HC-862

PSYCHOLOGY SERVICES
P.O. BOX 2415 Worker Counselling Authorization and Consent
EDMONTON, AB T5J 2S5
FAX: 780- 427-5863
1-800-661-1993

I, , authorize
(name of client) (name of Psychologist/Social Worker)

to provide me with psychological treatment services. I understand and agree that:

1. I may at any time decline or discontinue treatment with the psychologist/social worker. If this occurs, I
will contact my WCB claim owner to discuss the implications of this action.
2. My cooperation is a significant factor in my treatment and that treatment success is not guaranteed.
3. If further services are required beyond those supported by the WCB, appropriate referrals for alternate
assessment or treatment may be provided.
4. The use of any recording devices without the signed consent of both myself and the
psychologist/social worker is prohibited. Any violation may result in the termination of the services.
5. The psychologist/social worker will send reporting to the WCB that summarizes my treatment goals
and treatment progress. I can access reports generated from these treatment services through a
request to my WCB claim owner.
6. I understand that the information related to my treatment may be used for research regarding program
effectiveness. I understand that the intent of the use of this information is to improve psychological
services provided by the WCB.

The information collected by this psychologist/social worker is confidential and protected under the FOIP, the HIA, and the WCB Acts.
This collection of personal information is in compliance with section 33(c) of the Freedom of Information and Protection of Privacy Act,
Section 20(a) of the Health Information Act, and is collected under the authority of the Workers’ Compensation Act.

By signing this document below, I declare that I have read it, understand, and agree to the provision of
psychological services on the above basis.

Dated at , Alberta, this day of , 20


(city/town)

Witness signature Client signature

- OR -
If client is unable to sign or is a minor, signature of parent, guardian or legally authorized representative is acceptable.
Please include your relationship to client.

Witness name – PRINTED Client name - PRINTED

FOR USE WHEN INTERPRETER INVOLVED:


I have interpreted the contents of this document to the above client, and I am satisfied that the client
understands the content, purpose, and nature of this document and has accordingly agreed to it.

Witness signature Interpreter signature

Witness name - PRINTED Interpreter name - PRINTED

HC-862 REV JAN 2022 Page 1 of 1

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