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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 (ROW CSD) 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 achieve or move closer to your action plan goals.

To help with this, chiropractic care is being offered to people receiving Ontario Works and non-disabled family members of those on Ontario Disability Support Program (ODSP). This is to make sure that your action plan goals such as school/training programs or employment opportunities are a good fit for your physical abilities. The goal is to get you moving forward through your action plan goals towards employment.

If your action plan goal is to pursue a referral to ODSP, the chiropractor may be able to assist after assessing your physical abilities.  

Who will my information be shared with?

Chiropractors

Chiropractors participating in H2W are carefully selected and are in good standing with the College of Chiropractors of Ontario.

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, if applicable, will review requests for additional sessions from the community Chiropractor.

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.

In which city will you be attending this program?
 
Was verbal consent given from the client?
 
Clear
Clear
Clear
Clear

Considerations about Sharing Information

Why is sharing my information important for this program?

Sharing information helps the Chiropractors and ROW CSD staff 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. ROW CSD staff 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. ROW CSD staff 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 Ontario Works Caseworker or Employment Consultant any questions you may have. You can also limit or withdraw your consent at any time by speaking with your Ontario Works Caseworker or Employment Consultant. 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 Ministry of Community and Social Services Act, for the purpose of administering the Region of Waterloo’s Health 2 Work program.

For more information, contact the Manager of Employment & Income Support Services at 519-575-0661.