TELL US ABOUT YOURSELF:
This information assists us in helping you meet your needs at this time.
Please ensure all fields are COMPLETE and ACCURATE
Incorrect or incomplete information may impact our ability to respond to your request.
UR Student ID
*
First Name
*
Last Name
*
Age
*
Date of Birth
*
Gender
*
Preferred Email
*
Phone Number
*
Current Address
*
City
*
Postal Code
*
Relationship Status
*
Number of Children
*
I currently live with:
*
I'm registered through:
*
Choose Institution
University of Regina
Campion College
Luther College
First Nations University
My campus is located in:
*
Choose Location
Regina
Saskatoon Satellite
Prince Albert Satellite
Faculty or Program of Study
*
Have you seen a clinician at Student Mental Health before?
*
Select one:
No
Yes, previously
Yes, currently
If yes, provide the date-range (in years):
Have you accessed other community mental health services?
*
Select one:
No
Currently
Previously
If yes, provide the date-range (in years):
To qualify for services, I certify the following is true:
Please add a checkmark to acknowledge each of the following:
*
I am a registered student of the University of Regina and am attending the main campus, a satellite, or distance campus location. I am currently physically located in Saskatchewan. I have completed this form voluntarily and am requesting services for myself.
Briefly, my current concern is regarding:
*
This is impacting my life and ability to function in the following ways:
*
I have already tried to address my concern or cope with my situation by:
*
Things that might need to change so I can achieve the improvement I want in my life:
*
Any additional information you feel is important for us to know about you regarding: culture, ethnicity, religion, language, sexual orientation, gender identity/expression, mental or physical health, or other?
I would like my first appointment to be:
*
Select modality:
VIRTUAL - via Zoom for Healthcare
IN-PERSON in REGINA - at the Student Wellness Centre
IN-PERSON in SASKATOON - at the satellite campus location
Consent to Participate
As a client accessing Student Mental Health (SMH) services, you should be aware of the following important information before we start:
Add a check to acknowledge you have read and understand the following:
Student Mental Health (SMH) is not a crisis centre. I agree that if I find myself in a threatening or emergency situation, I will immediately call 911. If I require crisis-oriented mental healthcare services, I will contact 988 or my local primary healthcare facility/hospital. I can also contact the Canada Crisis Line by phone at: 1-800-668-6868 or by texting "U ofR" to 686868.
*
I understand, acknowledge, and accept.
SMH is not a 24/7 service. Office hours are generally 8:30 am to 4:30 pm, Monday through Friday (closed on holidays). I understand that, unless I have a pre-arranged appointment with my clinician, being seen immediately as a walk-in cannot be guaranteed.
*
I understand, acknowledge, and accept.
SMH clinicians do not monitor their voicemail and email accounts outside of office hours. SMH does not provide psychotherapeutic services via email or telephone.
*
I understand, acknowledge, and accept.
My assigned SMH clinician will contact me via my preferred email, as I have listed above, to schedule my appointment. I understand that it is my responsibility to ensure my email is entered accurately and is secure.
*
I understand, acknowledge, and accept.
SMH uses the OQ45.2 system as an outcomes measure (https://www.oqmeasures.com/about-oq/). The U of R’s Privacy Office and Information Services department have reviewed the security and privacy features of the OQ45.2. As it is used to track my treatment progress, I will be required to complete these brief survey measures. These are accessed via a unique URL link sent to my preferred email, as I have listed above. Only my assigned clinician and my clinician's supervisor will have access to these measures.
*
I understand, acknowledge, and accept.
The brief psychotherapeutic services offered by SMH aim to provide me with support to collaboratively devise strategies to help me manage my current concerns. However, despite the efforts of my clinician and myself, my situation may not improve, and in some cases may even get worse.
*
I understand, acknowledge, and accept.
Beneficial results cannot be guaranteed or assured. My clinician and I will assess, and in some cases reassess, the appropriateness of the therapy I am receiving. I agree to provide feedback to my clinician should I find the therapy is not meeting my needs. If the available psychotherapeutic services offered by SMH are not appropriate for my current situation or fit with my needs, I will be provided with alternatives, including resources and/or information about treatment options/providers that may be better suited. I understand that an opening with community providers may not be immediately available.
*
I understand, acknowledge, and accept.
I have the right to decline services from SMH, as well as withdraw my consent to participate at any time. Neither of these actions will jeopardize my access to future psychotherapeutic or related services offered by SMH.
*
I understand, acknowledge, and accept.
The federal and provincial privacy laws (e.g. Saskatchewan Health Information Protection Act), as well as the professional ethical standards of my clinician that protect the confidentiality of my health information, and apply to both in-person and virtual psychotherapeutic services. Information disclosed to me during my session (as well as via telephone, mail, or email) will, in general, be kept confidential and are only used in the provision of psychotherapeutic and related services. My personal health information will not be released without my written consent unless required (as noted below in the exceptions to confidentiality). Unless the situation is an emergency, consent must be provided in writing (signature required) and cannot be provided via telephone or email.
*
I understand, acknowledge, and accept.
There are exceptions to the confidentiality and privacy rights described above. These include, but are not limited to: reporting suspected neglect of or harm to a child; addressing imminent risk of serious harm to self or others; providing information in response to a subpoena or court order; providing information required by legislation (e.g. SGI or WCB); and as otherwise permitted under the Local Authority Freedom of Information and Protection of Privacy Act.
*
I understand, acknowledge, and accept.
In the event there is concern for my safety, as outlined above, my local emergency conact is:
Name
*
Phone
*
Relationship
*
The person listed above is aware they are identified as my emergency contact and has agreed to this role.
*
Yes, I certify this is true.
I may see a clinician that is a provisionally licensed psychologist. If this is the case, the clinician will inform me of their status and identify their clinical supervisor.
*
I understand, acknowledge, and accept.
My client file will be maintained electronically on a secure server with U of R's Information Services department. To further protect my privacy, this file is kept separate from other University files (e.g. academic, financial). Only my clinician and my clinician's immediate supervisor are permitted to access my client file. In exceptional circumstances, my file may be viewed if I am receiving services from a covering SMH clinician. This file will be maintained for 7 years following the date of the last service provided to me, as required by legislation. I understand I have a right to access my client file information during or after services have ended.
*
I understand, acknowledge, and accept.
On occasion, my clinician may need to reach me by phone (e.g. reschedule due to an unexpected absence; due to a power-outage; due to unforeseen technical difficulties during a virtual session).
*
I understand, acknowledge, and accept.
Important additional information about participating in Virtual Services:
The purpose of virtual psychotherapeutic services is the same as those provided in-person. However, due to the use of technology, I may notice some differences in my experience. I acknowledge that the structure and expectations for a virtual session are also the same as in-person services. For example, I can expect my appointment will be mutually pre-arranged during regular office hours and my clinician will be participating from their office on campus. My virtual appointment link will be sent to my preferred email, as I have listed above.
*
I understand, acknowledge, and accept.
Certain mental health concerns are not appropriate to be primarily addressed via virtual sessions. Some of these concerns include: acute and chronic crisis; recent psychiatric hospitalization; psychosis; substance abuse; eating disorders; moderate to severe mood/anxiety disorders; active risk of harm to self. If this is my situation, or becomes my situation in the future, more appropriate services or resources will be recommended.
*
I understand, acknowledge, and accept.
SMH uses "Zoom for Healthcare" to host my virtual therapy sessions. The U of R's Privacy Office and Information Services department have reviewed the security and privacy features of "Zoom for Healthcare" for this use.
*
I understand, acknowledge, and accept.
It is my responsibility to maintain privacy on the client-end of the transmission and communication. I will take precautions that include: using a private space and secure reliable internet connection, wearing a headset, and muting in the event of an unexpected interruption. It is the responsibility of my SMH clinician to do the same.
*
I understand, acknowledge, and accept.
I am expected to have my camera turned ON for the duration of my virtual therapy session. I am also expected to have a functioning microphone on the device I will be using for the session. The same expectations stand for my SMH clinician.
*
I understand, acknowledge, and accept.
Despite all reasonable technology security efforts, there remains a risk that the transmission and communication of my virtual session may be breached and accessed by unauthorized persons.
*
I understand, acknowledge, and accept.
By submitting this form, I acknowledge that I have read, understand, and accept all the above statements relevent to receiving psychotherapeutic or related services from the U of R's Student Mental Health Team.
