Health2Work Program Consent to Share Information 

Consent to sharing the personal information and personal health information defined below between the Region of Waterloo Community Services Department and the parties named below for the purpose of participating in the Health2Work Program.

About the Program:

The goal of the Health2Work Program is to help you deal with pain that stops you from being able to participate in training or get back to work.

To help with this, chiropractic care is being offered to people receiving Ontario Works. This program will also assist with making sure that training programs are a good fit for your physical abilities. The goal is to get you working again, whether it’s straight back to work, or through job training.

Who will my information be shared with?

Chiropractors

A community Chiropractor, who will do an initial assessment, discuss your health goals and provide treatment to help you reach your goals;

A lead Chiropractor, who will review the work of the community Chiropractor and approve treatment plans.

Community agencies

Community agencies that provide health and job training programming related to your specified health and employment goals

What will be shared?

Your employment history and goals

Your responses to the questionnaire about pain and relevant health issues

Attendance at chiropractic appointments and progress as a result chiropractic treatment

Only what information is required to determine your eligibility for their programs

I understand that I may withdraw or limit my consent at any time. I have read or had read to me and understand the consent set out above.

Considerations about Sharing Information

Why is sharing my information important for this program?

Sharing information helps the Chiropractors and your workers simplify access to services, determine which services you may qualify for, and to align services with your defined health and employment goals. Other benefits of sharing information may include eliminating the need to talk about your circumstances and provide copies of your identification multiple times. Your worker will only recommend sharing information with reputable agencies and where sharing information has benefitted citizens in similar situations in the past. Some of the services and supports include:

• transportation fee assistance
• physical capacity assessment
• identification of pain and exercises/tips to reduce/eliminate pain
• employment counselling and appropriate career selection
• counselling supports (if needed)

What information will be shared?

You decide what information is shared and what is kept private. Your worker will only ask to share information necessary to determine services and supports. This could include, for example, documentation to prove your identity, or information about your employment history, education or training history and the impact of health issues on ability to seek, gain or maintain these activities.

What if I have questions or change my mind about giving consent?

We encourage you to ask your worker any questions you may have. You can also limit or withdraw your consent at any time by speaking with your worker. Choosing to limit or withdraw your consent will not affect your eligibility for Region of Waterloo services or supports in any way.

Notice with Respect to the Collection of Personal Information

(Municipal Freedom of Information and Protection of Privacy Act)

This information is collected under the legal authority of the Ontario Disability Support Program Act, 1997, or the Ontario Works Act, 1997, or the Personal Health Information Protection Act, 2004, or the Housing Services Act, 2011, or Child Care and Early Years Act, 2014, or the Ministry of Community and Social Services Act, for the purpose of administering Government of Ontario social assistance programs and/or Region of Waterloo social programs.

For more information, please speak with your worker.