Muslim Family Services:Intake Assessment Form

Muslim Family Services: Intake Assessment Form

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Consent Form

CONFIDENTIALITY AND DISCLOSURE AGREEMENT

All identifying information
about counselling is kept confidential, except as mandated by law. You must sign a release of information before any information about you is given to anyone, except as mandated by law.
In certain situations, counselor is required by law to reveal information obtained during counselling session to other persons or agencies without your consent. In such situations, ICNA Relief is not required to inform you of his actions.

Please note the following exceptions to confidentiality:
· Confidentiality does not apply to the cases of suspected any abuse (physical, sexual, emotional or neglect) of children, elderly or direct threat to an individual.
· Confidentiality does not apply to cases of potential harm to self or others.
· A counselor may disclose confidential information in proceedings brought by a client against a professional.
· Confidentiality may not apply in cases involving legal proceedings affecting the parent-child relationship.
ICNA Relief is required law to protect the privacy of your health information. Although your counselling record is the physical property of ICNA Relief the information contained in your health record belongs to you.

Virtual Counselling limitations:
·ICNA Relief Canada offers virtual counseling via Microsoft Teams, and phone. While we prioritize your privacy, no method is fully secure, and there may be limitations with virtual sessions.
·Communication can be intercepted, intentionally or unintentionally.
·Poor reception may disrupt sessions, requiring rescheduling.
·Audio quality may affect clarity, and you may be asked to repeat yourself.
·To help protect your information, please use a personal device and secure interne connection
(e.g., home network over public Wi-Fi).
.Clients are not allowed to make an audio and video recording of any portion of the session.
.ICNA is not liable for confidentiality breaches when they are caused by client error.
·Choose a private space where you won’t be overheard or interrupted.

Review this confidentiality document and its limits.

We offer only non-emergency counselling services by appointment.

I confirm that all information given to ICNA Relief is accurate to the best of my/our knowledge, and that ICNA Relief shall not be held responsible for any error/omission and consequences in the handling of my/our case. *

Name *

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Date of Birth *

Phone *

Electronic Signature *

Clear Signature

Date Completed *