HPFS

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CONTACT HPS
Call HPS – 905-525-2832
HPS is open Monday to Friday 9:00am-5:00pm
(Closed daily 12:00pm-1:00pm)

Consent Form

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Authorize Invalid Input to disclose to disclosemy personal health information consisting of: Past and current Discharge Summaries including confirmation of psychiatric diagnosis and any of the following that maybe applicable: criminal activity, violence, incarceration, probation/parole, suicidal/homicidal ideation/attempts, social work history, vocational assessment, neuropsychological testing results. Invalid Input (Describe the personal health information to be disclosed) Invalid Input Or Orthe personal health information of: Invalid Input Invalid Input consisting of: (Describe the personal health information to be disclosed) Invalid Input
to IntAc – Intensive Case Management Access Coordination (Canadian Mental Health Association – Hamilton Branch, Community Mental Health Promotion Program – City of Hamilton, Hamilton Program for Schizophrenia, and Hamilton Mental Health Outreach)
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I understand the purpose for disclosing this personal health information to the agencies noted above is to determine my eligibility for case management services. I understand that I can refuse to sign this consent form.
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Signature

Sign Above

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Date:

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