Consent for Treatment Form

Do Not fill out this form until you have made contact with your Therapist.  This form will be filled out in partnership with them.

What is Social Work?

Social Work is a profession dedicated to helping individuals, families, groups and communities to enhance their individual and collective well-being.  The Social Work Profession Act defines the practice of social work as including the following objectives.

1.  To accomplish the core functions of social work including

      Helping people obtain services relating to the basic human needs 

      Counselling of individuals, familes and groups and

      Helping communities and groups provide or improve social and helath services

2.  To assess, remediate and prevent social problems encountered by individuals, familes and communities.

3.  To enhance individual, family and community social functioning. 

In Manitoba only members of the Manitoba College of Social Workers are authorized to use the title Social Worker or represent themselves as Social Workers, expressly or by implication.

"taken from the public secion of the Manitoba College of Social Workers"

"RSW - Registered Social Workers are a profession that can be covered by majority of insurance plans"  

Limits of Services and Assumption of Risks: 

Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions.

Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions.

Waiver

This Personal Injury Waiver (the "Waiver") is made by the undersigned for the purpose of the accompaniment of the therapist during Client In home services,  In community services , virtual, and in the acknowledgement that in the utilization of any premises, facilities and/or cloud-based video conferencing service of the Mobile Social Clinic, occupies risk of personal injury that may arise or happen at any time.

In consideration of the Mobile Social Clinic allowing the undersigned to  attend with company therapist and make use of any venue and its facilities, equipment and/or cloud-based video conferencing service for the relevant purpose by which the therapist and client access, the undersigned agrees to assume the foreseeable and unforeseeable risk of personal injuries related to the activity, and agrees to release, discharge, and hold harmless Mobile Social Clinic, its owner(s) and employees free from any and all liabilities, claims, cause of action, damages, or losses, which may be incurred by the undersigned in using said premises and its equipment and/or facilities, and which may arise from any reason whatsoever, specifically including, but not limited to, any negligence on the part of the owners, its employees, or losses arising from theft or for any other reason whatsoever.

 
This Waiver shall be binding upon the parties, their respective heirs, representatives, successors, and assigns.

 
In case any part of this Waiver be construed as improper or invalid, such invalidity will affect only that part of this Waiver and the rest shall remain valid and enforceable.

Any alteration, modification, or amendment to this Waiver shall not be considered as valid unless otherwise written and signed by the undersigned herein.

Limits of Confidentiality:

What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian. The following is a list of exceptions:
Duty to Warn and Protect
If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.
Abuse of Children and Vulnerable Adults
If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate agency and/or legal authorities.
Prenatal Exposure to Controlled Substances Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.
Minors/Guardianship
Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.
Insurance Providers
Insurance companies and other third-party payers are given information that they request regarding services to the clients. The type of information that may be requested includes: types of service, dates/times of service, diagnosis, treatment
plan, description of impairment, progress of therapy, case notes, summaries, etc.

For direct billing service review and complete Telus Health eClaims Electronic Transmission Authorization and Consent Form. 

 

CANCELLATION POLICY

If you are unable to attend an appointment, we request that you provide at least 24 hours advanced notice to our office. Since we are unable to use the session time for another client,  $120.00 will be charged to you for the entire cost of your scheduled appointment.  
For cancellations made with less than 24 hour notice (unless due to illness or an emergency) or a scheduled appointment that is completely missed, you will be mailed a bill directly for the full session fee.
We appreciate your help in keeping your therapy schedule running in a timely and efficient manner. 

Mobile Social Clinic Phone Number & email

204-253-7072

info@mobilesocialclinic.com