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______________________________________________________________________________________________________________________

Section A: Program Overview(required)

Consent for Services:
I consent to receive services from Hospice Orillia. I agree to collaborate with the staff from Hospice Orillia to create my care plan and goals of care, which will be reviewed periodically. I understand that I have the right to withdraw my consent for services at any time.

Eligibility, Exclusion, and Transition Criteria
I understand that in order to receive services from Hospice Orillia, I must meet the eligibility criteria listed below:
• Be 16 years of age or older
• Experiencing a progressive life-threatening illness or caring for someone who is currently receiving care at Mariposa House Hospice

I understand that if I no longer meet the eligibility requirements (e.g. moving out of service area), or if my needs extend beyond the capacity of Hospice Orillia (e.g. client needs extend beyond volunteer scope, counselling outside of Community Social Worker's scope), the staff will work with me in order to facilitate the transition of care.
I understand that Hospice Orillia has the right to withdraw services if a risk is identified which would place Hospice Orillia staff in an unsafe environment (e.g. aggressive or discriminatory behaviour, active infestation), or if I do not make contact with the Community Social Worker for a continuous period of three months.

Confidentiality & Release of Information
I understand that all personal information shared with Hospice Orillia staff is confidential, as per the Personal Health Information Protection Act of 2004. I understand that information sharing between the service providers in my circle of care shall be for the sole purpose of providing quality service to meet my care needs. I understand that if my safety or another person’s safety is at risk, Hospice Orillia has the duty to report. I understand that I have the right to withdraw this consent at any time. I understand I am able to request my personal health information at any time by advising the staff member most responsible for my care, and my information will be available within two business days. In some circumstances, access may be refused as per current privacy legislation.

I give consent to Hospice Orillia to:
Share my personal health information in the Hospice Orillia Community Program, and with the other Community Social Workers employed by Hospice Orillia as needed to complete my goals of care.
Receive and share all personal health information with all healthcare providers within my circle of care.
Share my personal health information at Community Rounds as needed to ensure continuity of care.
Complete quarterly Quality of Care surveys with myself or (enter the name of whom we are permitted to conduct Quality of Care surveys with):

who is my (enter relationship)

Fees for Service
I understand that Hospice Orillia does not charge any fees for their services. I understand that this is made possible through funding from the North Simcoe Muskoka Home and Community Care Support Services (previously known as North Simcoe Muskoka Local Health Integration Network (LHIN)) and generous donations from the community.

Program Scope & Rights and Responsibilities
I acknowledge that I have been informed of my rights and responsibilities as a client of Hospice Orillia, and the scope of the Social Work Support Program. A copy of these documents have been provided to me, and I have been advised of the complaint procedure.

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Section B: Waiver & Acknowledgement (required)
I agree to release and hold harmless Hospice Orillia along with its directors, volunteers and employees of all actions, claims or demands of any nature or kind arising out of or in any way connected with the provision of service by Hospice Orillia except if claims arise from intentional or deliberately harmful or criminal actions.

I have read the provisions of this agreement and understand their meaning.

This service agreement is valid for one year, and will expire one year from the date of submission.

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Form completed by:
ClientPower of AttorneySubstitute Decision MakerGuardian
Name:
Date: