Encompas Mental Health Wellness Program Consent to Service Form
- About Encompas
- Consent to Service
The Encompas Mental Health Wellness Program provides eligible OPPA members with timely access to confidential, effective and safe mental health support and services that are customized just for them. The program is powered by, and independently managed by, Dalton Associates, a mental health services organization that has served Ontarians since 1995.
Every eligible OPPA member who reaches out to Encompas will be provided with support service navigation, advocacy, a tailored Plan of Care, and timely access to mental health services by a dedicated Care Manager. The Encompas Care Manager is the member’s one point of contact for any mental health service question or need that arises.
I understand that my participation in the program is entirely voluntary, and that I have the right at any time to cease participation in the program by notifying Dalton Associates. I understand that my relationship with Dalton Associates and my Encompas Care Manager will be governed by the provisions in this consent form.
I give permission and consent to my Encompas Care Manager to provide me with ongoing:
- Mental health support service navigation for the duration of my enrolment in the program;
- A documented, customized, and evolving Plan of Care/Service, that is developed specific to my mental healthcare needs;
- Access to my Plan of Care and other mental health and wellness resources through the secure Encompas Member Portal;
- Appropriate follow-up and check-in support via telephone or email for the duration of my enrolment in the program; and,
- Appropriate follow-up with the Encompas mental healthcare providers (e.g., counsellors, psychologists, etc.) providing me with care, to ensure cohesive, comprehensive care.
I understand that my Care Manager is responsible for developing my Plan of Care, and activating the services therein planned, with my full and informed consent.
I understand that my right to confidentiality is respected at all times. I understand that the Ontario Provincial Police Association (OPPA) and the Ontario Provincial Police (OPP) do not have access to my information through the program, and that none of my information will be shared with the OPPA or OPP. I understand that anonymized, aggregate data will be shared with the OPPA for the purposes of evaluating the program. I also understand that none of my information will be communicated, directly or indirectly, to any other third party without my informed and written consent, except when mandatory reporting legislation requires, by law of all mental health services, that Encompas Case Managers and clinicians:
- Inform a potential victim of violence of a client’s intention to harm them;
- Inform an appropriate family member, health care professional, or emergency services if necessary, of a client’s intention to end his or her life;
- Provide a copy of a record when there is a court order, warrant or subpoena to do so;
- Inform the Children’s Aid Society (CAS) / Family and Children’s Services (FACS) if there is suspicion of a child being at risk of, or in need of, protection due to neglect, or physical, sexual (inclusive of child pornography), or emotional abuse;
- Report a health professional who has sexually abused a client; and,
- Report elder abuse in long term care facilities.
I understand that monitoring my progress and counselling outcomes, as well as my satisfaction with my mental healthcare services, has been proven by research to improve the mental health service experience and the outcomes I may receive from counselling.
Powered by Greenspace, the Encompas Self-Assessment Platform is compliant with Canadian privacy legislation, is accessible via computer, tablet or cellphone, and ensures ease of monitoring symptoms. If it is appropriate for my care, I understand that my Encompas Care Manager or my clinician will orient me to the use of the Encompas Self-Assessment Platform but that my use of the Platform is entirely voluntary and, should I choose not to use it, I will still have full access to the program. If I do choose to use the Encompas Self-Assessment Platform, I understand that I may opt-out of participating at any time.
- My Encompas Care Manager will need to collect and document some personal information about me;
- Dalton Associates’ administrative staff, and the Encompas Care Management and Clinical Leadership teams may need to access some of my personal information solely for the purpose of administering the program, and that their access is governed by the same confidentiality obligations as set out herein limited;
- I have the right to review and the right to access my file and my personal information; and,
- My Care Management record will be securely maintained electronically, in a manner that is compliant with PHIPA and PIPEDA legislation.
I understand how the Privacy Policies apply to me, which can be viewed on the Encompas website at: www.encompascare.ca/privacy-policy. Should I have any questions or concerns about this policy, I understand I can speak with my Encompas Care Manager.
I understand that the Encompas program has established Policies and Procedures for Accessibility Services in accordance with the Accessibility for Ontarians with Disabilities Act (AODA). I understand that the Encompas Accessibility Services Policy may be viewed on the Encompas website at www.encompascare.ca/accessibility.
I understand that my Care Manager is not available for emergency services, but are able to connect me with immediate support services through the Encompas Crisis Support Team. In the case of an emergency, I understand that I should dial 911 or go to the Emergency Department of any hospital.
I understand that there are risks in transmitting data over the internet. To protect my personal information, I understand that I should use secured internet connections, and should clear my browser cache after accessing the program.
I further understand that email and text messages can be compromised, and so their use should be limited to appointment information only (e.g., date, time and location). Transmitting personal health information by email is permitted only when absolutely necessary, and by attaching password-encrypted PDF documents, versus including the information in the body of an email.
I understand that the program data will be stored secure server, and that the server is located in a Tier 4 facility. I understand that this is not a shared server, that the organization is SOC certified, and that there are various protocols in place (e.g., back-up server, encryption, and firewalls) to ensure the safety and security of the data.
I have read and understood the information presented in this document, I have had the opportunity to ask any questions I may have about this document and the program, and hereby consent to the services described above.
I agree that should I choose to acknowledge electronically; my electronic acknowledgment is the legally binding equivalent to my handwritten signature. My electronic acknowledgment has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic acknowledgment or claim that my electronic acknowledgment is not legally binding.
USE OF THE SERVICES IS NOT FOR EMERGENCIES. IF YOU HAVE A MEDICAL OR MENTAL HEALTH EMERGENCY, OR IF AT ANY TIME YOU ARE CONCERNED ABOUT YOUR CARE OR TREATMENT, CALL 911 OR GO TO THE NEAREST OPEN CLINIC OR EMERGENCY ROOM.
IF YOU ARE CONSIDERING OR CONTEMPLATING HARMING OR KILLING YOURSELF OR ARE CONCERNED THAT YOU ARE A DANGER TO YOURSELF OR TO OTHERS, YOU MUST DISCONTINUE USE OF THE SERVICES IMMEDIATELY, CALL 911 OR GO TO THE NEAREST OPEN CLINIC OR EMERGENCY ROOM.
- Documents Incorporated by Reference
A “Treatment Provider” is a regulated professional who is permitted to provide psychotherapy services and is registered as a Therapist on the Platform. Treatment Providers may include, but are not limited to, psychiatrists, psychologists, social workers, occupational therapists, and psychotherapists. “Treatment Providers” include employees, agents, or independent contractors of Treatment Providers.
A “Primary Care Provider” is a regulated professional who is permitted to provide health care services and is registered as a Primary Care Provider on the Platform (and together with a Treatment Provider, a “Provider”). Primary Care Providers may include, but are not limited to, physicians and nurse practitioners.
The Platform includes, without limitation, the following services (collectively, the "Services" ):
- the facilitation of the delivery of assessments to You as provided by you or your child's Treatment Provider(s) and/or Primary Care Provider(s), as applicable;
- the display of the results of such assessments to You and your Treatment Provider(s) and/or Primary Care Provider(s);
- the creation and storage of progress notes by your Treatment Provider(s) and/or Primary Care Provider(s);
- if requested, matching You with a Treatment Provider; and
- the provision of other information about the Company and our products and services through the Platform.
For clarity, the Company is not a provider of telemedicine or telemedicine services.
THE SERVICES DO NOT INCLUDE THE PROVISION OF HEALTH CARE SERVICES, MENTAL HEALTH SERVICES OR SOCIAL OR PSYCHOTHERAPY SERVICES, OR ANY OTHER PROFESSIONAL SERVICES BY THE COMPANY. The Company is simply a technology service provider that facilitates the Services through the Platform.
PROVIDERS ARE NOT THE EMPLOYEES OR AGENTS OF THE COMPANY AND ARE NOT CREDENTIALED BY THE COMPANY. THE COMPANY DOES NOT HAVE ANY OVERSIGHT OF THE CARE PROVIDED TO YOU BY PROVDERS. Each Provider is an independent practitioner who is solely responsible for any health care services or social or psychotherapy services provided to you, and is also solely responsible for obtaining your informed consent, where required, to any medical treatment, including without limitation, your consent to use the Services, to the extent such consent is required by applicable provincial/territorial legislation.
While the Services may provide access to certain general medical information, the Services cannot and are not intended to provide medical advice. We advise you to always seek the advice of a physician or other regulated health professional with any questions regarding your personal health or medical conditions. Never disregard, avoid, or delay in obtaining medical advice from your physician or other regulated health professional because of something you have read on the Website. If you have or suspect that you have a medical problem or condition, please contact a physician or other regulated health professional immediately.
THE CONTENT ON THE WEBSITE IS NOT AND SHOULD NOT BE CONSIDERED MEDICAL ADVICE OR A SUBSTITUTE FOR INDIVIDUAL MEDICAL ADVICE, DIAGNOSIS, OR TREATMENT. YOU SHOULD ALWAYS TALK TO YOUR PHYSICIAN OR OTHER REGULATED HEALTH PROFESSIONAL FOR DIAGNOSIS AND TREATMENT, INCLUDING INFORMATION REGARDING WHICH DRUGS OR TREATMENT MAY BE APPROPRIATE FOR YOU. NONE OF THE INFORMATION ON THE WEBSITE REPRESENTS OR WARRANTS THAT ANY PARTICULAR DRUG OR TREATMENT IS SAFE, APPROPRIATE, OR EFFECTIVE FOR YOU.
Access to certain portions of the Platform, Services and Content is restricted to users registered on the Platform.
There is no guarantee that you will be accepted as a registered user. Even if you are accepted as a registered user and (i) have a pre-existing connection with a registered Treatment Provider or Primary Care Provider; (ii) or are matched with a Treatment Provider, your Treatment Provider or Primary Care Provider may determine that use of the Services is not appropriate for some or all of your treatment needs, and accordingly may elect not to facilitate your use of the Services.
In order to access the Private Portal and certain of the Services you will be required to complete an online registration form and become a registered user of the Platform by creating an account (“Account”). To create an Account, you must be of legal age to form a binding contract. If you are not of legal age to form a binding contract, you may not register to use our Services.
In consideration for your use of the Platform and the Services provided on it, you agree to provide true, current, complete and accurate information as requested on any registration form to which the Platform may direct you, and to update that registration information as soon as possible after any information on such registration form changes.
Upon registration, you will choose a username and password. You alone are responsible for keeping that password and username confidential, and for any and all activity that occurs on the Platform under such password or username. You agree to immediately notify the Company of any unauthorized use of your password or username or any other breach of security.
By consenting to receive the Services using the Platform, you consent to the inherent material risks associated with the electronic uploading, transmission and storage of your Personal Information. By providing or uploading any of your Personal Information to the Platform, you are consenting to the collection, use and disclosure of your Personal Information for the purposes of providing the Services to you and for consistent purposes. Although the Company uses advanced encryption technology and other security protocols to protect your Personal Information, you acknowledge by using the Platform that there are inherent risks to any technology however remote that could cause security protocols to fail or be breached, which could result in the unauthorized collection, use or disclosure of your Personal Information. The Company will notify you to the extent required by law of any security protocol failure or breach that has resulted in in the unauthorized collection, use or disclosure of your Personal Information.
Your or your child's medical care and your mental health care are solely the responsibility of you and your Provider(s), as applicable.
Under the Services, mental health care services or social or psychotherapy services are provided exclusively by Treatment Providers and/or Primary Care Providers. The Company supports Providers by providing them with a license to use our intellectual property rights, including our patent pending inventions, trade secrets, copyrights, trademarks, service marks, trade dress and proprietary and confidential information and access to The Company's technology platform. However, exclusive control and responsibility for the delivery of mental health care services or social or psychotherapy services is reserved to Providers.
All Treatment Providers available through the Platform represent that they are permitted to provide psychotherapy services and are a member in good standing with the regulatory college of their jurisdiction. The Company requires Treatment Providers to represent and warrant that that they are in good standing with their respective regulatory college and to immediately apprise the Company of any changes to such status. The Company conducts limited credential checks and other verifications of Treatment Providers and the information they have provided to the Company. However, the Company is not responsible for credentialing Treatment Providers, makes no representation regarding the accuracy of Treatment Providers’ credentials, and expressly disclaims any liability for fraudulent credentials or claims by Treatment Providers. In addition, changes in your Treatment Provider’s professional status after we perform an initial credential check. We recommend that you separately confirm that your Treatment Provider is in good standing with his or her respective regulatory college.
All Primary Care Providers available through the Platform represent that they are permitted to provide health care services and are a member in good standing with the regulatory college of their jurisdiction. The Company requires Primary Care Providers to represent and warrant that that they are in good standing with their respective regulatory college and to immediately apprise the Company of any changes to such status. The Company conducts limited credential checks and other verifications of Primary Care Providers and the information they have provided to the Company. However, the Company is not responsible for credentialing Primary Care Providers, makes no representation regarding the accuracy of Primary Care Providers’ credentials, and expressly disclaims any liability for fraudulent credentials or claims by Primary Care Providers. In addition, changes in your Primary Care Provider’s professional status after we perform an initial credential check. We recommend that you separately confirm that your Primary Care Provider is in good standing with his or her respective regulatory college.
If you are referred to the Platform by a Primary Care Provider and complete an intake questionnaire to be matched with a Treatment Provider, your personal information and progress results will be available to both Providers. By submitting such a request to be matched with a Treatment Provider, you expressly consent to the use of electronic means to share such personal information and progress results with both Providers.
- upload, post, email or otherwise transmit any Content (as defined in Section 13 below) to which you do not have the lawful right to copy, transmit and display (including any Content that would violate any confidentiality or fiduciary obligations that you might have with respect to the Content);
- use the Services to collect or store personal data about other users without their express permission;
- knowingly include or use any false or inaccurate information in any profile;
- circumvent, disable, or otherwise interfere with security-related features of the Services or features that prevent or restrict use or copying of any Content;
- attempt to probe, scan or test the vulnerability of any Company system or network or breach or impair or circumvent any security or authentication measures protecting the Services;
- attempt to decipher, decompile, disassemble, reverse engineer, or otherwise attempt to discover or determine the source code of any software or any proprietary algorithm used to provide the Services;
- use the Services in any way that competes with the Company, including, without limitation, misrepresenting one’s identity or posing as a current or prospective patient in order to solicit or recruit Treatment Providers, directly or indirectly; or
- encourage or instruct any other person or entity to do any of the foregoing.
Your use of the Services and Content is at your sole discretion and risk. The Services and Content, and all materials, information, products and services included therein, are provided on an “AS IS” and “AS AVAILABLE” basis without warranties of any kind.
THE COMPANY AND ITS LICENSORS AND AFFILIATES EXPRESSLY DISCLAIM ALL WARRANTIES OF ANY KIND, EXPRESS, IMPLIED, OR STATUTORY, RELATING TO THE SERVICES AND CONTENT, INCLUDING WITHOUT LIMITATION THE WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT OF PROPRIETARY RIGHTS, COURSE OF DEALING, OR COURSE OF PERFORMANCE. THE COMPANY AND ITS LICENSORS AND AFFILIATES MAKE NO WARRANTY THAT THE CONTENT YOU ACCESS ON OUR WEBSITE OR USING OUR SERVICES SATISFIES THE LAWS AND REGULATIONS REQUIRING THE DISCLOSURE OF INFORMATION FOR PRESCRIPTION DRUGS.
IN ADDITION, THE COMPANY AND ITS LICENSORS AND AFFILIATES DISCLAIM ANY WARRANTIES REGARDING SECURITY, ACCURACY, RELIABILITY TIMELINESS AND PERFORMANCE OF THE SERVICES OR THAT THE SERVICES WILL BE ERROR FREE OR THAT ANY ERRORS WILL BE CORRECTED. NO ADVICE OR INFORMATION PROVIDED TO YOU BY THE COMPANY WILL CREATE ANY WARRANTY THAT IS NOT EXPRESSLY STATED IN THESE TERMS OF SERVICE.
WE MAKE NO REPRESENTATIONS CONCERNING, AND DO NOT GUARANTEE, THE ACCURACY OF THE SERVICES, INCLUDING, BUT NOT LIMITED TO, ANY INFORMATION PROVIDED THROUGH THE SERVICES OR THEIR APPLICABILITY TO YOUR INDIVIDUAL CIRCUMSTANCES. OUR SERVICES AND WEBSITE CONTENT ARE DEVELOPED FOR USE IN CANADA AND THE COMPANY AND ITS LICENSORS AND AFFILIATES MAKE NO REPRESENTATION OR WARRANTY CONCERNING THE SERVICES OR WEBSITE CONTENT WHEN THEY ARE USED IN ANY OTHER COUNTRY.
THE LAWS OF CERTAIN JURISDICTIONS, INCLUDING QUEBEC, DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LEGAL WARRANTIES, LIABILITY OR CERTAIN DAMAGES OR LIMITATIONS OF REPRESENTATIONS MADE CONCERNING GOODS OR SERVICES. IF THESE LAWS APPLY TO YOU, SOME OR ALL OF THE BELOW EXCLUSIONS OR LIMITATIONS MAY NOT APPLY TO YOU.
In particular, you agree to indemnify and hold harmless the Company, its affiliates, members, directors, officers, employees, agents, sponsors, and licensors for any injury, including but not limited to bodily harm or death, to you or any third party that may result from the use of or reliance on any Content.
NOTHING HEREIN SHALL LIMIT THE POTENTIAL PROFESSIONAL LIABILITY OF THE TREATMENT PROVIDERS OR OTHER LICENSED HEALTHCARE PROFESSIONALS ARISING FROM OR RELATED TO MEDICAL OR MENTAL HEALTH ADVICE, DIAGNOSIS, OR TREATMENT THEY PROVIDE TO YOU, EXCEPT AS PROVIDED UNDER APPLICABLE PROVINCIAL/TERRITORIAL LAWS. IN MANY JURISDICTIONS, TREATMENT PROVIDERS ARE REQUIRED TO REPORT CONFIDENTIAL INFORMATION IF THEY HAVE REASON TO BELIEVE THAT A PATIENT IS LIKELY TO HARM OTHERS OR HIMSELF/HERSELF. IN NO EVENT SHALL THE COMPANY BE LIABLE FOR THE DISCLOSURE OF YOUR CONFIDENTIAL INFORMATION BY A TREATMENT PROVIDER FROM WHOM YOU RECEIVE MENTAL HEALTH SERVICES OR SOCIAL OR PSYCHOTHERAPY SERVICES. THE COMPANY IS NOT LIABLE TO ANY PERSON OR USER FOR ANY HARM CAUSED BY THE NEGLIGENCE OR MISCONDUCT OF A TREATMENT PROVIDER PROVIDING MENTAL HEALTH SERVICES. IN NO EVENT WILL THE CUMULATIVE LIABILITY OF THE COMPANY OR THE COMPANY’S LICENSORS OR AFFILIATES TO YOU, WHETHER IN CONTRACT, TORT, OR OTHERWISE, EXCEED $1,000.
The information on the Platform may contain typographical errors or other errors or inaccuracies, and may not be complete or current. The Company reserves the right to correct any errors, inaccuracies, or omissions and to change or update information at any time without prior notice to you. The Company will not, however, guarantee that any such errors, inaccuracies, or omissions will be corrected. The Company reserves the right to refuse to fill any orders or provide Services that are based on inaccurate or erroneous information on the Platform, including, without limitation, incorrect or out-of-date information regarding pricing, payment terms, or for any other lawful reason.
You may terminate your Account at any time and for any reason by providing written notice to the Company. Upon any termination by you, your Account will no longer be accessible. Any cancellation request will be handled within 30 days of receipt of such a request by the Company.
You agree that it is the express wish of the parties that this agreement and all related documents be drawn up in English. Vous êtes d'accord que c’est la volonté expresse des parties que la présente convention ainsi que les documents qui s’y rattachent soient rédigés en anglais.
Last Update: April 9, 2020