Consent – Employee Assistance Program

Statement of Understanding and Consent

Please read the following information carefully. If you have any questions, please ask the psychologist to explain this information further.

I agree to participate in a consultation with a psychologist at TFD Services.  I understand this service is provided under an Employee Assistance agreement with my employer and is limited to 3 sessions. I also understand that under certain circumstances the number of sessions may be extended, but there’s no guarantee of this.

Confidentiality

I understand that all my personal information will be treated in confidence. The only time confidence may be broken is when a “duty of care” legally overrides the “duty of confidentiality” held by the psychologist. Specifically, confidentiality may be overridden:

• Where failure to disclose information you have given would place you or another person at serious risk of harm.

• Where the information you have given is subpoenaed (officially requested) by a Court of Law.

• Where you provide prior approval to discuss your personal information.

Exchange of Information

I understand and agree that my personal information may, at the psychologist’s professional discretion, be exchanged with other staff of TFD Services for case discussion and/or supervision purposes.

Recordkeeping

I understand that my personal information will be kept on file at TFD Services, in secure storage, not accessible to any personnel outside of TFD Services.

Reports

Because of the short-term, restrictive nature of Employee Assistance counselling, reports will not be prepared for workers’ compensation, legal, insurance or family court purposes. We will provide a statement of counselling attendance, if requested. We will not provide a copy of your file to any third party. However, we will provide you with a copy of your folder notes upon a direct request from you on an official request form available upon application.

Cancellation Policy

If, for some reason you need to cancel or postpone the appointment, notification is required by close of business the day prior to your scheduled appointment. Failure to do so or attend an appointment will result in losing that session entitlement under the EAP.