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Community Program – Consent for Service

Community Program - Consent for Service

Client Information:

Preferred Pronoun

Emergency Contact Information:

Preferred Pronoun (Emergency Contact)
Type of SDM *

Family Doctor (or other professional involved in your care):

The mission of Bethell Hospice is to provide excellent person-centered, palliative care through partnerships within our community. Values of the organization include: Compassion, Integrity, Accountability, Excellence, Teamwork and Courage.

Palliative Care, according to the World Health Organization, is “prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” A holistic approach is used to provide symptom management and comfort in all the domains of issues: physical, disease management, psychosocial, spiritual, practical, death management, grief and bereavement. The focus is on the resident’s goals of care and quality of life, not hastening or postponing death. Supportive care is provided in collaboration with a multidisciplinary team.

Consent for Service *
I, or my substitute decision maker (SDM), consent to receive services from Bethell Hospice. I understand that I may withdraw this consent at any time by verbal notification, which will result in discontinuation of hospice services.
Release of Information *
• I give consent for my personal and medical information to be shared with Bethell Hospice Residential Program and with Bethell Hospice Community services.
• For the purposes of ensuring continuity of care, I authorize Bethell House/Hospice to receive and to share my personal health information with all healthcare partners within my circle of care.
• I understand that if at any time I no longer wish my personal or medical information to be shared with others, as stated above, then I must notify Bethell Hospice in writing of my request.
I acknowledge that I have been informed of my rights and responsibilities as a Bethell Hospice client. A copy of the Bethell Hospice policy Rights of Person Served has been given to me.
PRIVACY and Confidentiality *
• I understand that all personal information will be treated as private and confidential as per the Personal Health Information Protection Act, 2004.
• I understand that information sharing between Bethell Hospice personnel shall be for the sole purpose of providing quality service to meet my needs and those of my family. I understand that all personal information will be treated as private and confidential. Safety supersedes confidentiality when persons are at risk.
• I acknowledge that I have been informed of the eligibility and exclusion criteria for Bethell Hospice Community Program, and the protocol for transition from Bethell Hospice programs. A document containing this information has been provided to me.
• I am aware that my care needs will be reviewed and my care plan updated as required.
• If my condition improves or stabilizes to the point where I no longer require and/or am eligible for Bethell Hospice Community Program, I understand Bethell Hospice can withdraw services.
• I understand that Bethell Hospice staff and volunteers are not medical personnel and are unable to determine the nature of a medical emergency. I understand that if a Hospice staff or volunteer is alone with a client who experiences a medical emergency – 911 will be called unless a signed valid DNR is in the home. If the medical emergency is unrelated to the diagnosis (ie a client fall), 911 will be called. In the event of a concern for the emotional or physical wellbeing of a client, the staff or volunteer may call the Mobile Crisis Unit of Peel.
• Bethell Hospice endeavors to provide a safe and respectful environment. Deliberate aggressive and/or threatening behaviour (physical, emotional, psychological, sexual) is not tolerated towards staff and volunteers of Bethell Hospice, nor other clients, families and friends. I understand that if this occurs, a warning will be issued, police may be called and/or service may be terminated.
• I understand that due to the high number of referrals for the programs and services offered, there is a potential for service provision to be delayed. If a program is not running or is at capacity at the time I am referred to it/or request it, my name will be placed on a ‘wait-list’ until it becomes available.
I understand that volunteers are part of the Bethell Hospice team who are trained to work in specific roles and contribute to my experience while enrolled in service with Bethell Hospice.
• I understand and accept the conditions noted above. I agree to release and indemnify Bethell Hospice or any directors, officers, volunteers, agents and employees from all claims and liability for any of the following:
1. Personal injury, illness, incapacity, or death that occurs, or
2. The loss of money, valuables and personal effects unless held in safe keeping by the Hospice
3. Loss of property or damage (unless intentionally committed)
4. Any care provided to me other than by the employees and agents of the Hospice
• I agree to release Bethell Hospice along with its directors, officers, volunteers, agents 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 services by Bethell Hospice except if claims arise from intentional or deliberately harmful or criminal actions.
I understand that the services of the residential and community programs are provided at no cost thanks to the generosity of donors, community partners and government funding. Financial donations, in-memoriam donations and bequests are gratefully accepted. To discuss donation opportunities, please contact the Foundation office at foundation@bethellhospice.org.
Bethell Hospice Foundation

Bethell Hospice programs and services are provided free of charge due in part from the generosity of donations to Bethell Hospice Foundation. Contact information for clients and their emergency contact/substitute decision maker is shared with Bethell Hospice Foundation for the purpose of receiving updates and news.

In addition to my emergency contact/substitute decision maker, please notify the following person of any gifts made in my honour or memory:

AODA Statement *
Bethell Hospice is committed to providing an accessible experience in which all individuals have equal access to our services and facilities as required by the Accessibility for Ontarians with Disabilities Act, 2005.
I agree to all provisions of this agreement and understand their meaning. *

Messages sent via the internet can be intercepted. If you are concerned about providing your personal information by email or website form submission, please contact us directly at 905-838-3534 to arrange for an alternate method of communication.

For more information, please refer to our Bethell Hospice Privacy Statement.

Thanks to our Funders