CONSENT AND AUTHORIZATION FORM

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CONSENT FOR FREE CONSULTATION
CONSENT FOR 2 HOURS FREE CONSULTATION
I,
(name of authorizing person):



  • Understand that 24/7 Home Support And Care Inc.Home Care provider has taken into consideration my best interests in their professional judgement
  • Understand that 24/7 Home Support And Care Inc.will only share personal information about me to appropriate authority (the Social Welfare Authority/my family Physician) that is directly relevant to abuse and maltreatment suspected by 24/7 Home Support And Care Inc provider for the purposes of protecting my health and safety.
  • Understand that MY personal information is protected under the Privacy Act. I am aware that every individual has a right to access the personal information about himself or herself and that the information may only be used or disclosed within the conditions set out in that Act.
  • Understand that I may withdraw or amend my consent in writing at any time by contacting 24/7 Home Support And Care Inc. Management.
  • Understand that should I not give consent to the disclosure of information,24/7 Home Support And Care Inc. may still have the authority to share my personal information with the appropriate Authority as authorized under the Privacy Act.
  • Have read the above statements, understand the content of this Consent Form and chose to give my consent voluntarily for 24/7 Home Support And Care Inc. to collect information about me for assessment of my needs for care and support purposes.
  • Understand that agreement will be made between me and 24/7 Home Support And Care Inc.to contract the service provision of my needs after the assessment.
  • Understand that 24/7 Home Support And Care Inc. would need my Permission/authorization to commence my care and support services as agreed upon in the assessment.



Name (print) :
Signature :
Date
date_range
If this Consent Form is signed by a Parent/Guardian/Substitute Decision Maker/authorized person, please specify the relationship.
Name
Signature
Relationship:
Date
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24/7 Home Support And Care Inc. A North American Home Support And Care Partner
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