Consent Form

Thank you for reaching out to the Student Mental Health Team!

AIM of our Services: To provide psychotherapeutic support for a current pressing mental health related concern.

FORMAT: Scheduled appointments with a Student Mental Health clinician that are solution-focused and collaborative in nature. Length can range from 30-50 minutes, depending on the current need, and are offered either virtually (via Zoom for Healthcare) or in-person.

YOUR PARTICIPATION: Willingness to actively engage (1) during the session to work alongside your clinician, and (2) with session content/tasks following the session. Session content aims to help facilitate insight, options, or actionable solutions to your current pressing concerns. This may include: psychoeducation, therapeutic strategies, skill-developing tools, or resource suggestions.

PLEASE TELL US ABOUT YOURSELF

This information assists us in helping you meet your needs at this time.
**Please ensure all fields are COMPLETE and ACCURATE**
Incorrect or incomplete information may impact our ability to respond to your request.

* UR Student ID * Faculty and Program of Study
* First name * Last name
* Age * Gender
* Address * Postal Code
* Phone * Email
Relationship Status* Number of Children*
* Registered through
U of R Campion College Luther College First Nations University
Have you seen a clinician at Counselling Services before? Yes, year(s) No
Have you had a Time Limited Consult (TLC) session?
Yes, year(s) No
Have you accessed other community mental health services?
Currently Previously, years(s) No

To qualify for counselling services, I certify that:

Please add a checkmark to acknowledge:

I am a registered student of the University of Regina and attending the main campus, a satellite, or distance campus location.
I am currently physically located in Saskatchewan.

Briefly, my current concern is regarding:

This is impacting my life and ability to function in the following ways:

I have already tried to address my concern or cope with my situation by:

What might need to change so that I can achieve the improvement I want in my life?

Is there anything else you feel is important for us to know about your culture, ethnicity, religion, language, sexual orientation, gender identity/expression, mental or physical health, or other?

I would like my first appointment to be:
Virtual via Zoom for Health Care
In-Person at the Student Wellness Centre (119 Paskwāw Tower)


CONSENT TO PARTICIPATE

As a client accessing our services, there are very important details you should be aware of before we start:

I understand that Student Mental Health is not a crisis centre. I agree that if I find myself in a threatening or emergency situation, I will immediately call 911. If I require crisis-oriented mental health care services, I will contact my local primary health care facility/hospital. I can also contact the Canada Crisis Line by phone at: 1-800-668-6868 or by texting "UofR" to 686868.
I understand that Student Mental Health is not a 24/7 service. Office hours are generally 8:30 am to 4:30 pm, Monday through Friday (closed on holidays). I understand that, unless I have a pre-arranged appointment with my clinician, being seen immediately by a clinician as a walk-in cannot be guaranteed.
I understand that clinicians do not monitor their voicemail and email accounts outside of Student Mental Health's office hours.
The brief psychotherapeutic services offered by Student Mental Health aims to provide me with support in collaboratively devising strategies to help manage my current concerns. However, despite the efforts of myself and my clinician, my situation may not improve, and in some cases may get worse.
I understand that beneficial results cannot be guaranteed or assured. My clinician and I will assess, and in some cases reassess, the appropriateness of service delivery. I agree to provide feedback to my clinician should I find that the delivery format is not meeting my needs. If the available psychotherapeutic services offered by Student Mental Health are not appropriate for my current situation or fit with my needs, I will be provided with alternatives, including resources and/or contact information for more applicable treatment or service providers in my area. I understand that an opening with community providers may not be immediately available.
I have the right to decline services from Student Mental Health, as well as withdraw my consent to participate at any time. Neither of these actions will jeopardize my access to future psychotherapeutic or related services offered by Student Mental Health.
The federal and provincial privacy laws (e.g. Saskatchewan Health Information Protection Act), as well as the professional ethical standards of my clinician that protect the confidentiality of my health information, apply to both in-person and virtual psychotherapeutic services. I understand that information disclosed to me during my session (as well as via telephone, mail, or email) will, in general, be kept confidential and are used in the provision of psychotherapeutic and related services. I understand that my personal health information will not be released without my written consent unless required (as noted below in the exceptions to confidentiality). Unless the situation is an emergency, consent must be provided in writing (signature required) and cannot be provided via telephone or email.
I understand there are exceptions to the confidentiality and privacy rights described above. These include, but are not limited to: reporting suspected neglect of or harm to a child; addressing imminent risk of serious harm to self or others; providing information in response to a subpoena or court order; providing information required by legislation (e.g. SGI or WCB); and as otherwise permitted under the Local Authority Freedom of Information and Protection of Privacy Act.
In the event there is concern for my safety, as outlined above, my local emergency contact is:

Name:

Phone:

Relation:

I may see a clinician that is a provisionally licensed psychologist. If this is the case, the clinician will inform me of their status and identify their clinical supervisor.
My client file will be maintained electronically on a secure server with University of Regina's Information Services department. To further protect my privacy, this file is kept separate from other University files (e.g. academic, financial). Only my clinician and my clinician's immediate supervisor are permitted to access my client file. This file will be maintained for 7 years following the date of the last service provided to me, as required by legislation. I understand I have a right to access my client file information during or after services have ended.
I understand that, on occasion, my clinician may need to reach me by telephone (e.g. reschedule due to an unexpected absence or power-outage; unforeseen technical difficulties during a virtual session).

Additional important information about participating in VIRTUAL SERVICES includes:

I understand that the purpose of virtual psychotherapeutic services is the same as those provided in-person. However, due to the use of technology, I may notice some differences in my experience. I acknowledge that the structure and expectations for a virtual session are also the same as in-person services. For example, I can expect my appointment will be mutually pre-arranged during regular office hours and my clinician will be participating from their office on campus. I prefer my virtual appointment link be sent to:
Email:
I understand that certain mental health concerns are not appropriate to be primarily addressed via virtual sessions. Some of these concerns include: acute and chronic crisis; recent psychiatric hospitalization; psychosis; substance abuse; eating disorders; moderate to severe mood disorders; active risk of harm to self. If this is my case, or becomes the case in the future, more appropriate services or resources will be recommended.
Student Mental Health uses Zoom for Healthcare to facilitate virtual sessions. I have reviewed the Zoom privacy policy at: https://zoom.us/healthcare. I understand that this is the only modality used for virtual sessions. Student Mental Health does not provide virtual psychotherapeutic services via email, telephone, or other service providers.
It is my responsibility to maintain privacy on the client-end of the transmission and communication. I will take precautions that include: using a private space and secure reliable internet connection, wearing a headset, and muting in the event of an unexpected interruption. It is the responsibility of the clinician to do the same.
I understand that, despite all reasonable technology security efforts, there remains a risk that the transmission and communication of my virtual session may be breached and accessed by unauthorized persons.

I acknowledge that I have read, understand, and accept all the above statements relevant to receiving psychotherapeutic or related services from the University of Regina's Student Mental Health team.