Skip to content
154 Cannifton Road North, Belleville, K8N 4Z6
613 689 7783
Moss Psychology
My WordPress Blog
Home
About Us
F.A.Qs
Fees and Policies
Meet The Team
Resources
Cogmed
Psychologists of Ontario
Client Login
Free Mental Health Resources
Services
Online Services
In-Person Services
Clinical Supervision and Consultation
Adults
Children and Adolescents
Couples and Families
Seniors
Treatments
Cognitive Analytic Therapy (CAT)
Emotionally Focused Therapy (EFT)
Eye Movement Desensitization and Reprocessing (EMDR)
COGMED
Contact Us
Get In Touch
Client Feedback
Home
About Us
F.A.Qs
Fees and Policies
Meet The Team
Resources
Cogmed
Psychologists of Ontario
Client Login
Free Mental Health Resources
Services
Online Services
In-Person Services
Clinical Supervision and Consultation
Adults
Children and Adolescents
Couples and Families
Seniors
Treatments
Cognitive Analytic Therapy (CAT)
Emotionally Focused Therapy (EFT)
Eye Movement Desensitization and Reprocessing (EMDR)
COGMED
Contact Us
Get In Touch
Client Feedback
Military Consent To Release
You are here:
Home
Military Consent To Release
Please select the language to complete questionnaire - Veuillez choisir une langue pour compléter les questionnaire
(Required)
Please Select - Veuillez sélectionner
English
French
Military Consent To Release
CONSENT TO DISCLOSE PERSONAL HEALTH INFORMATION
(PURSUANT TO THE PERSONAL HEALTH INFORMATION PROTECTION ACT 2004)
I hereby authorize Moss Psychology to exchange my personal mental health information with the Mental Health Unit at 8 Wing Trenton for the following purposes: Mental health evaluation, treatment and/or care and treatment planning.
The information to be disclosed may include mental health evaluations, including developmental, educational, alcohol/substance use, forensic, and social history, clinical session notes and progress reports. I have had the opportunity to discuss this consent and fully understand this request/authorization to release records and information, including the nature of the records and their contents. This request is entirely voluntary on my part. I understand that I may take back this consent at any time, except to the extent that action based on this consent has already been taken. This consent will expire automatically after one year from the date on which it is signed, or upon fulfillment of the purposes stated above.
If you have any questions or concerns regarding the consequences and implications of releasing any aspect of your personal health information to the Canadian Military, these should be directed to the Mental Health Unit at 8 Wing Trenton.
Name
(Required)
First
Last
Date of Birth
(Required)
DD dash MM dash YYYY
Service Number
(Required)
Consent Form Acceptance.
(Required)
Yes
I have read, fully understand, and agree to this consent form
Consentement de divulgation pour militaire
CONSENTEMENT POUR DIVULGUÉE DE L’INFORMATION PERSONNELLE
(CONFORMÉMENT À LA LOI DE 2004 SUR LA PROTECTION DES RENSEIGNEMENTS PERSONNELS SUR LA SANTÉ)
Je, par la présente, autorise Moss Psychology à partager mon information personnelle sur ma santé mentale avec l’unité de santé mentale de la 8e escadre de Trenton pour les raisons suivantes : évaluation en santé mentale, traitement et/ou soins et planification de traitement. L’information divulgué peut inclure mon évaluation en santé mentale (incluant mon développement, éducation, alcool/consommation de substances, situation légale, historique sociale, notes de sessions et rapports de progression. J’ai eu l’occasion de discuté ce consentement et comprend pleinement cette demande/autorisation de divulguer les dossiers et informations. Ceci inclue la nature des dossiers et leur contenu. Cette demande est entièrement volontaire de ma part. Je comprends que je peux retirer mon consentement en tout temps, sauf dans les mesures où des actions basées sur ce consentement ont déjà été prises. Ce consentement expire automatiquement un an après la date de signature, ou une fois que les conditions ci-dessus ont été remplies.
Si vous avez des questions ou des inquiétudes par rapport aux conséquences et répercussions reliées à tout aspect de divulgation de vos renseignement personnels aux Forces Armées Canadiennes, veuillez les diriger au département de santé mentale de la 8e escadre de Trenton.
Nom
(Required)
First
Last
Date de naissance
(Required)
DD dash MM dash YYYY
Numéro de service
(Required)
Acceptation du formulaire de consentment
(Required)
Oui
J’ai lu, je comprends pleinement et j’accepte ce formulaire de consentment.
Go to Top