During our counselling relationship you will reveal personal information to me such as name, gender, date of birth, address, phone number, family status, employment information, names of family members etc…. I will be keeping progress notes, reports and assessments. It is my responsibility as a Privacy Officer at this Private Practice to protect your personal information, which I have in my possession. 

• Collection, use and disclosure of personal information will be done with your knowledge and consent, except in the above identified limits to confidentiality. 
• The collection, use, disclosure and retention of the client’s personal information will be limited to the purposes for which it is collected and will be kept accurate, complete and up to date. 
• Unless there is an emergency, I will not collect private information about you without your consent. 
• I collect and record only information that I believe is needed to provide you with service. 
• To ensure quality of service and as part of my commitment to professional development engage in regular clinical supervision. Some of your information (date we met, topics we covered, progress, interventions, next steps for therapy) will be shared with my practice supervisor to find ways to improve services to you, to identify and correct risks and errors. Safeguards are in place to ensure protection of all clinical files in supervision. 
• The privacy of your information is protected through established procedures in my office as follows: All private information is kept in a secure, locked filing cabinet. Electronic information about you is encrypted and password protected. 
• Information about you occasionally may be seen by persons who are carrying out an audit or a review of my practice. 
• Information about you will be disclosed to persons outside my office only with your consent, except (a) in situations in which disclosure is justified by law or by my profession’s code of ethics (e.g., risk of serious bodily harm; need for confidential professional or legal consultation); and (b) in situations in which disclosure is required by law (e.g., reporting a child in need of protection; reporting a health professional who has sexually abused a client; a court order to release information about a record). 
• When giving me permission to disclose information about you, the consent for release of information to third parties must specify the information to be released (i.e. full or partial record), the party to whom the information will be released, and how long is the consent valid for. However, if the information you do not want disclosed is clearly needed by the person receiving the information to provide you with appropriate service, I am required by law to inform the person receiving the information that you have refused consent to provide some necessary information. 
• With only a few exceptions, you have the right to see your record of service and to request copies of information in your record. Exceptions include the possibility of harm to you or someone else, and confidential information in the record about a person other than yourself. 
• If you believe that information in your record is not accurate, you may request that I correct the information. If I do not agree with the correction you request, you may file a notice of disagreement into your record. 
• I will speak with you directly to answer any questions you have regarding this Privacy Policy, and to provide you with any further privacy practices or limits to confidentiality that are specific to your situation. 
• If you would like more detailed information; at any time, would like to access or ask for a correction of your record; have a concern about my privacy policies and procedures; or have a complaint about the way your privacy has been handled, please do not hesitate to speak with me. 
• If you have a concern or complaint and are not satisfied with my response, you may contact the Information and Privacy Commissioner of Ontario (416) 326-3333 or 1-800-3870073.