By booking a Clinical Therapist Consultation with a Licensed Therapist (“Care Team”), I indicate my consent which authorises Alavida Health Ltd. (“Alavida”) to collect the information needed for the Care Team to deliver the educational session and provide best answers to my questions as possible.

We will never share your personal information with anyone without your prior consent. If you would like to review the Alavida PRIVACY POLICY in full, it can be found on our website at the following address: www.alavida.co/privacy.

PERSONAL INFORMATION

By accepting this form, I agree that I have given my informed consent to the collection, use, and/or disclosure of my personal information as outlined in the Alavida PRIVACY POLICY. I have reviewed the Alavida PRIVACY POLICY and understand how Alavida will use my personal information and the steps that Alavida is taking to protect my information. I agree that Alavida can collect, use, and disclose personal information as set out in the Alavida PRIVACY POLICY.

CONTENTS

I understand that the Clinical Therapist Consultation is not charged, unless I fail to change my consultation by no later than 24 hours to my scheduled time, or if I fail to show up. In this case, I authorise Alavida to charge a cancellation fee of $100 plus applicable taxes.

The Clinical Therapist Consultation will consist of a 40 minute appointment with the Care Team wherein my personal information, treatment programs and/or other care alternatives will be discussed. I will have the opportunity to ask questions that relate to helping motivate a loved one to make change and basic information on getting started and understanding how problem drinking develops, how change takes place and different options for support and treatment with the Care Team. Due to the time-limited nature of the Clinical Therapist Consultation, I understand that I will not have the ability to discuss an assessment about the drinkers mental health or medical history and that this session will not be a comprehensive review of family medical or mental health history.

CANCELLATION OF APPOINTMENT

In the case that an appointment cannot be kept, Alavida requires 24 hours’ (excluding weekends and holidays) notice to cancel or reschedule appointments. In the event that I am unable to provide sufficient notice I understand that my appointment will be considered “missed” and I will be charged the cancellation fee in full.

LIMITS OF CONFIDENTIALITY

Information discussed with Alavida’s Care Team is confidential, and is not shared without the client’s written permission except under the following circumstances:

  • If the client is judged to be at serious risk of doing significant harm to himself or herself, or to someone else.
  • If the client reports information indicating that a vulnerable person is in need of protection (e.g. a child or elderly person being abused).
  • If the client holds a driver’s license and is not safe to be operating a motor vehicle.
  • If records are subpoenaed by a court of law.

In addition to these limits, information discussed with Alavida’s Care Team may be shared among other Alavida care team members for the purposes of providing personalized follow-up after the session, as outlined in the Alavida PRIVACY POLICY.