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Use: When a documentation request involves sharing a client’s records with, or obtaining records from, a person or organization outside the clinic (e.g., physician, insurer, lawyer, ICBC, WorkSafeBC, CVAP). Also use when a client requests a copy of their own records for a personal reason.

Not for: Case discussion among Head & Heart counsellors. That uses the Release of Information (ROI) form in JaneApp (see Required forms checklist (new clients)).

Storage: Store the signed form in the client’s JaneApp Notes section. Admin completes the Office use only section when records are released.

Policy: Associates send this form to clients by email. Admin sends the records by encrypted email. See Release of records policy.

Important: Records must not be released until this form is fully completed and signed. If the request involves legal proceedings or court, contact Katherine/admin before releasing anything.

Form to send to clients

Download the fillable PDF — Consent for Release of Information

How to send it:

Download the PDF from the link above.
Fill in Section 2 (your name and designation) before sending, so the client doesn’t have to.
Email it to the client as an attachment. Ask them to complete all sections that apply, sign, and email it back. Clients can type into the form and tick the boxes in Adobe Acrobat Reader, Preview (Mac), or most browsers, then sign with the viewer’s signature tool. They can also print it, sign by hand, and send a scan or photo.
When it comes back, check that Sections 3–8 and the client signature are complete, then store it in the client’s JaneApp Notes section.
Notify admin. Admin sends the records by encrypted email and completes the Office use only section. Associates do not send records themselves (see Release of records policy).

The full text of the form is below for reference.

Head and Heart Counselling Inc.

806-318 Homer St., Vancouver, BC V6B 2V2
604-787-4008 | katherine@headandheartcounselling.com | headandheartcounselling.com
Katherine Young, M.Ed., RCC – Clinical Director

Authorization to Disclose and/or Obtain Clinical Records

Head and Heart Counselling Inc. protects the privacy of your personal information in accordance with British Columbia’s Personal Information Protection Act (PIPA) and the ethical standards of the BC Association of Clinical Counsellors (BCACC). Your information is not shared without your written consent, except where the law requires or permits it. Please complete all sections that apply.

1. Client information

Full name: ___________
**Date of birth (DD/MM/YYYY)**: ______
**Address**: ___________
Phone: ________ **Email**: ________

2. Clinic and counsellor

Clinic: Head and Heart Counselling Inc., 806-318 Homer St., Vancouver, BC V6B 2V2 | 604-787-4008
Counsellor name and designation: _____________

3. Authorization

I authorize Head and Heart Counselling Inc. and my counsellor named above to (check one):

Release information to
Obtain information from
Exchange information with (two-way)

the person or organization named below.

4. Person or organization

Name: ________ **Organization**: ________
Address: ___________
**Phone**: ________ Email: ________

5. Information to be released

Records dated from: ______ to: ______ (leave blank for all dates of service)

6. Purpose of disclosure

Continuity of care / coordination of treatment
Insurance or extended benefits claim
Legal proceedings
ICBC / WorkSafeBC / Crime Victim Assistance Program (CVAP)
Personal request
Other: ________

7. Method of release

Secure (encrypted) email
Pick-up by client
Verbal consultation

8. Expiry

This authorization expires on (check one):

Date: ________
Event: ________

If no date or event is given, this authorization expires one year from the date I sign it.

9. My rights

Voluntary: Signing this form is my choice. I may refuse to sign it.
No condition on services: My counselling services do not depend on whether I sign this form.
Right to revoke: I may revoke this authorization in writing at any time (see Section 11). Revoking it does not apply to information already released before the clinic received my written revocation.
Re-disclosure: The person or organization receiving my information may not be bound by the same confidentiality obligations, and the information could be disclosed again by them.
Copy of this form: I may request a copy of this signed form.
Limits of confidentiality: Apart from this authorization, my counsellor may be required or permitted by law to share information without my consent, such as when there is a risk of serious harm to me or others, a child may be in need of protection, or a court orders the release of records.

10. Signatures

I have read and understand this form, and I consent to the release of information as described above.

Client Signature: ___________ Date: ______

If the client is under 19 or has a legal representative:

Parent / guardian / representative name: ___________ Relationship: ______

Signature: ___________ Date: ______

Witness / counsellor:

Name: ________ Signature: ________ Date: ______

11. Revocation of authorization

I revoke this authorization. I understand that this does not apply to information already released.