X

Living Healthy Champlain Health Coaching Participant Consent Form

The Self-Management Health Coach Program is one of Living Healthy Champlain programs. The program is supported by Ontario Health and operates under and is supported by Bruyere Health. This telephone-based coaching program supports individuals living with chronic conditions to become better self-managers. As part of the program, participants are paired with trained volunteer Health Coaches based on gender, age, shared chronic health conditions or life circumstances.

In order to maximize your success in the Self-Management Health Coach Program, members of the Health Coach Program Team will request personal information from you. This information will include, but may not be limited to:

• Your name, address, email address and phone number;
• Information regarding your chronic condition(s);
• Barriers you may face in meeting your goals; and
• Goals and actions you want to take to better manage your health.

All information collected will be directly related to your participation in the Self-Management Health Coach Program. The information will be collected in electronic form and stored on our secure, password protected, website which can only be accessed by the Chronic Disease Self-Management team at Bruyere Health. Your personal information will only be used for the purposes of the Self-Management Health Coach Program. This information may also be used for program quality improvement purposes or research purposes in a de-identified aggregate format.

By clicking “Yes” are confirming you understand that:

• You are agreeing to provide relevant personal information to the Self-Management Health Coach Program;
• All information you provide will be kept strictly confidential and will only be accessible to members of the Health Coach and Living Healthy Champlain Team.
• Members of the Health Coach Team will use the information you provide for the sole purpose of maximizing your success in the Self-Management Health Coach Program.