{"id":900,"date":"2024-10-01T10:22:30","date_gmt":"2024-10-01T15:22:30","guid":{"rendered":"https:\/\/aurora.carmis.ai\/?page_id=900"},"modified":"2024-11-28T15:14:43","modified_gmt":"2024-11-28T21:14:43","slug":"newcomer-collaborative-community-mental-health-program-consent-for-psychiatric-consultation","status":"publish","type":"page","link":"https:\/\/aurora.carmis.ai\/fr\/newcomer-collaborative-community-mental-health-program-consent-for-psychiatric-consultation\/","title":{"rendered":"Programme de collaboration communautaire en sant\u00e9 mentale pour les nouveaux arrivants\u00a0: consentement \u00e0 une consultation psychiatrique"},"content":{"rendered":"<div id=\"cs-content\" class=\"cs-content\"><div class=\"x-section e900-e1 mp0-0 formbg\"><div class=\"x-row x-container max width e900-e2 mp0-1 mp0-2 innerformbg\"><div class=\"x-row-inner\"><div class=\"x-col e900-e3 mp0-3 NsdSpacerSmallAll\"><script>\nvar 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class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8'  action='\/fr\/wp-json\/wp\/v2\/pages\/900#gf_8' data-formid='8' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third CLIENT_UNQCODE exclude field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_8_6'>GUID<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_8_6' type='text' value='' class='large'   tabindex='1'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third exclude field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_8_17'>reqCode<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_8_17' type='text' value='' class='large'   tabindex='2'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_18\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third F_413 exclude field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_8_18'>userEmail<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_18' id='input_8_18' type='email' value='' class='large' tabindex='3'    aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full START_DATE exclude field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_8_4'>Submission Date (Admin Only)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_8_4' type='text' value='24\/06\/2026' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon' tabindex='4'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_4_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_4_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_4' class='gform_hidden' value='https:\/\/aurora.carmis.ai\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_15\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please review the following statements regarding your consultation with Resilia Community Wellness Centre's Psychiatrist, Dr. Peter Czaplinski. Please enter your initial after each statement if you agree.<\/div><div id=\"field_8_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full F_405 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_9'>I understand that I am participating in a consultation with psychiatrist, Dr. Peter Czaplinski for the purpose of assisting my therapy at Resilia Community Wellness Centre.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_8_9' type='text' value='' class='small'   tabindex='5'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full F_406 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_10'>I understand that a letter with any recommendations may be sent to my family physician.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_8_10' type='text' value='' class='small'   tabindex='6'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full F_407 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_11'>I have spoken with my therapist about the risks and benefits of a psychiatric consultation.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_8_11' type='text' value='' class='small'   tabindex='7'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full F_408 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_12'>I consent to my therapist, the Director of Mental Health Services and Dr. Czaplinski exchanging any relevant information to assist in the consultation and my therapy at Resilia Community Wellness Centre.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_8_12' type='text' value='' class='small'   tabindex='8'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_14\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Alternatively, if the person is not able to read and understand this document (in English) and as a result is not comfortable (agreeing) to sign, the person can provide verbal consent by stating in the person\u2019s own language \u201cI agree to consent to a consultation with Dr. Czaplinski and accept the terms and conditions of the Consent to Psychiatric Consultation Form\u201d. The Clinician and other Resilia Staff and\/or interpreter by signing this document are confirming the person understood what was explained and that the person is agreeing to consent and the person accepts the terms and conditions of the Consent to Psychiatric Consultation Form. <\/div><div id=\"field_8_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full F_409 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_13'>Please have the interpreter enter their name below attesting they have interpreter the above information to the client.<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_8_13' type='text' value='' class='small'   tabindex='9'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_16\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr><\/div><div id=\"field_8_20\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third D_401 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_20'>Date Signed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_20' id='input_8_20' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon' tabindex='10'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_20_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_20_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_20' class='gform_hidden' value='https:\/\/aurora.carmis.ai\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third FIRST_NAME gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_7'>Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_8_7' type='text' value='' class='large' 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