Life Beyond Cancer Intake Form

LIFE Beyond Cancer Intake

"*" indicates required fields

For many people, the transition after cancer treatment is integral to their healing and recovering. There are often questions and uncertainties about how to move forward and adapt to the change that has occurred. This program is intended to support people in this phase of transition after active treatment.

The screening questions below will help determine if this program is a fit for you. If you are unable/unwilling to check any of the boxes below, this program may not be a fit for you at this time. If you would like more information or to discuss further, please contact us by phone or email at info@inspirehealth.ca.

*This program will be offered online via Zoom. Participation will require stable internet and a device with access to video and audio. A cellphone is not recommended for group programming due to limited screen space for engaging with the larger group.

Name*

First Last

Phone*

Email*

Date of Birth*

Cancer Diagnosis*

Are you currently receiving cancer treatment?*

Yes

Please specify:

* Please note that treatment can look different for each person, some examples of treatment might look like: surgery, chemotherapy, radiation, or other complimentary or alternative treatments.

Question 1

1. In this program, we will be making space for discussion and personal sharing. To protect the privacy of all participants, we request that each person join from a private space where the videos and voices of other participants will not be seen by others in the household.

By checking this box, you agree with the following statement: I have a computer or tablet with video and audio capability and a private space to participate from.

Question 2

2. This program is designed for people who have had a cancer diagnosis. This program is not for support people.

By checking this box, you agree with the following statement: I have or had a cancer diagnosis and consider myself to be in the transition period after active treatment.

Question 3

3. As the group is intended to create connection between participants and offer a group experience similar to being in person, we request that videos remain on as much as possible.

By checking this box you agree with the following statement: I am willing to participate in small groups and keep my video on as much as possible.

Question 4

4. This program is offered weekly for four weeks. For you to get the most out of the program we ask that you commit to all 4 weeks. We understand that life happens and you may have to cancel a session, but ask you to make your best effort to attend all 4.

By checking this box you agree with the following statement: I commit to attending all 4 sessions.

Do you have any questions?

What is your hope for taking this program?

Is there anything else we should know?

CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION*

Consent to group services and telemedicine:

Confidentiality:

InspireHealth’s multidisciplinary team works as one unit of confidentiality and care, ensuring that any collaboration and communication is done with the utmost respect and ethical consideration. Confidentiality is an essential part of InspireHealth’s practice. Your privacy is important to us. Your healthcare information belongs to you and is held in confidence by InspireHealth, with the exception of the following circumstances:
1. If the information is required by law to be disclosed (e.g., a child or vulnerable person may need protection, the information is subpoenaed, or court ordered to be released).
2. If staff believe there may be a significant risk of harm to you or to others.
3. When informed and voluntary consent is provided by you to release information.

Patient records: Attendance will be tracked and documented in a secure electronic medical records system, which is encrypted and only accessible by InspireHealth clinical staff. Email communication will be used for program communication and coordination, please note that email content may become part of your InspireHealth chart.

Telemedicine: InspireHealth offers the option to access individual and group services through telemedicine, which is the use of telephone and/or video conference platforms. Participation in telemedicine is completely voluntary. At any point, you can choose not to access telemedicine services and speak with an InspireHealth staff member about alternative options for receiving support. If you choose to utilize telemedicine services, InspireHealth will not take video and/or audio recordings of the session. Video calls will be hosted through TELUS Business Connect and Zoom, which are both PIPEDA and PHIPA compliant. For TELUS Business Connect’s privacy policy visit: www.telus.com/privacy. For Zoom's privacy policy visit: https://zoom.us/privacy/. When participating in individual or group services through telemedicine, InspireHealth clinicians assure they connect from a secure and private setting. Confidentiality may be limited on the end of the participant(s). It is each participant’s responsibility to assure they are in a private and secure setting. As InspireHealth cannot assure the environment of participants, we cannot take responsibility for confidentiality being upheld by participant(s).

I acknowledge that I have read and understand the provisions in this form and consent to participate in InspireHealth group services through telemedicine.

By checking this box you understand that we will be in touch with you shortly. You will receive a confirmation and next steps via email. Please make sure to check your junk/spam folder and add noreply@inspirehealth.ca to your safe sender's list.

* Please note that completing this intake form does NOT guarantee you a spot. There are limited spaces and we will contact you to confirm registration and waitlist.

LIFE Beyond Intake

LIFE Beyond Cancer Intake