Support Person Intake Form

"*" indicates required fields

Support Person Information

Full Name*

First Name Last Name

Name of Patient you are supporting*

First Name Last Name

What do you like to be called (if different from above):

Pronoun

This will help us better understand how to address you (e.g.: She lives in Vancouver).

Primary Phone*

Email*

Date of Birth*

Personal Health/Care Card Number

Emergency Contact Information

Full Name of Emergency Contact*

Full Name Relationship

Primary Phone*

Consent

Support People of InspireHealth requesting services have the right to Informed Consent; that is, your full and active participation in decisions which affect you and your freedom of choice based on the information shared. InspireHealth respects your right to ongoing informed consent at the outset of the therapeutic relationship and throughout your care. You have the right to withdraw consent at any time and terminate services. When it comes to the direction and goals of your therapy, you are the primary decision maker. You have the right to accept or reject any task, exercise, or practice suggested by your clinician, and to be informed of the risks, benefits, rationale, alternatives, and interpretations of all suggested interventions.

Hidden

Consent

E-Signature*

First Name Last Name

Date*