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ProHealth Informed Consent
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(ProHealth Informed Consent Form) Process: I have been informed: Of the advantages and disadvantages of the intervention as well as related options, where necessary; That, as the process goes on, I am invited to express my positive or negative reactions about the process and achievement of objectives; That I can withdraw my consent and end the intervention at any time, but that I should first discuss it with the mental health care professional to become fully aware of the reasons behind my decision. Record: I am also aware that the mental health professional will maintain a record in which the progress of the therapeutic process is described: The content of this record is strictly confidential; Any personal information transmitted to a third party other than the EAP cannot be shared without me signing a specific consent letter; The only rare situations in which these rules do not apply have been explained to me; I can have access to my record unless the mental health professional deems it might be detrimental; The mental health care professional will have to provide the EAP summary information about my record. This information will be used for usage statistic purposes only. Information that could be used to identify an EAP user will not be given under any circumstances. Frequency of appointments and absences: Should I need to cancel an appointment, I will notify the mental health care professional at least 24 business hours in advance. Otherwise, I am aware and understand that I will lose 60 minutes of consultation time allowed under the Employee Assistance program, after which the professional will apply his or her own policies. The mental health care professional will notify me at least two weeks before his/her vacation dates and I will do the same. I have read and understood the contents of this form. I hereby consent to the process as stated above. Name (Signature)
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Informed Consent Form Process I have been informed: Of the advantages and disadvantages of the intervention as well as related options, where necessary; That, as the process goes on, I am invited to express my positive or negative reactions about the process and achievement of objectives; That I can withdraw my consent and end the intervention at any time, but that I should first discuss it with the mental health care professional to become fully aware of the reasons behind my decision. Record I am also aware that the mental health professional will maintain a record in which the progress of the therapeutic process is described: The content of this record is strictly confidential; Any personal information transmitted to a third party other than the EAP cannot be shared without me signing a specific consent letter; The only rare situations in which these rules do not apply have been explained to me; I can have access to my record unless the mental health professional deems it might be detrimental; The mental health care professional will have to provide the EAP summary information about my record. This information will be used for usage statistic purposes only. Information that could be used to identify an EAP user will not be given under any circumstances. Frequency of appointments and absences Should I need to cancel an appointment, I will notify the mental health care professional at least 24 business hours in advance. Otherwise, I am aware and understand that I will lose 60 minutes of consultation time allowed under the Employee Assistance program, after which the professional will apply his or her own policies. The mental health care professional will notify me at least two weeks before his/her vacation dates and I will do the same. I have read and understood the contents of this form. I hereby consent to the process as stated above.
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