Tranquility by Inkblot: Therapist-assisted iCBT

 

Informed Consent

(“Informed Consent Form”)

PLEASE REVIEW EVERYTHING CAREFULLY, IN PARTICULAR THE DISCLAIMER AND RELEASE SECTIONS BELOW.

Tranquility by Inkblot is an Internet-based Cognitive Behavioural Therapy (iCBT) program. iCBT is CBT delivered via digital platforms. In iCBT, the platform itself is the intervention. iCBT provides individuals with skills that can be used to improve their mental health and increase their quality of life. Tranquility’s iCBT program aims to help return you to wellness by providing you with tools and techniques to cope with life’s challenges. CBT is one of the most established and highly effective evidence-based therapeutic models. 

Confidentiality and Emergency Services. 

All calls will be recorded for quality assurance, research, and training purposes. All of the information you share with your iCBT therapist and/or within the platform is strictly confidential and will only be accessible by your therapist and Tranquility’s Clinical and Support staff, except in the following circumstances:

  • There is a serious and imminent risk of harm to yourself or another person. This may include situations where there is disclosed use of substances that cause impairment while working in a safety-sensitive position. Please note that after the initial 12-week period, therapists will no longer be monitoring your messages or screens for safety concerns. 

  • There is suspicion that a child/children, (governed under the age of protection in your province), or a vulnerable or elderly person has been or is being abandoned, abused or neglected,

  • You have provided to Tranquility your consent, in writing through a signed Release of Information Form, to share with specified others, not already identified in this Informed Consent Form, information concerning your iCBT program,

  • Disclosure as required by law, or

  • Your clinician is not able to reach you after you have indicated that you are at serious and imminent risk of harm to yourself. In this case, the clinician will call your emergency contact to determine if you are safe.

In addition, your therapist will disclose information and records to Tranquility by Inkblot’s Clinical Services Team as needed for coordination of services, quality assurance, or payment.  

PLEASE NOTE: Tranquility is not an emergency service, if you ever feel you’re in an emergency, please call 911 or go to the nearest emergency room. 

Home Address

Your therapist will ask for your home address and confirm that you are at that location at the beginning of each call. They will only ever use this for emergency purposes (for example if you had a health emergency and they needed to call for help for you).

24 Hour Policy

If you need to cancel or reschedule, please do so 24 hours before the scheduled call so that we can open that spot up for someone else to get the help they need. 

DISCLAIMERS

By signing this Informed Consent Form, to the extent permitted by applicable law, you agree that: 

  1. NO MONITORING AFTER TWELVE WEEKS. AFTER THE FIRST TWELVE WEEKS OF THE PROGRAM, ALTHOUGH YOU MAY HAVE ACCESS TO THE ICBT PLATFORM, YOU ARE USING THE ICBT PLATFORM AT YOUR OWN RISK AS INKBLOT DOES NOT MONITOR ANY OF YOUR RESPONSES (EVEN IF YOU INDICATE THAT YOU ARE AT RISK OF HARMNG YOURSELF OR OTHERS) OR NOTIFICATIONS, AND WILL NOT DISPATCH EMERGENCY AUTHORITIES TO YOUR LOCATION IN THE EVENT OF ANY EMERGENCY. YOU UNDERSTAND THE SCOPE, NATURE AND EXTENT OF THE RISKS INVOLVED IN YOUR CONTINUED USE OF THE ICBT PLATFORM AND FREELY AND VOLUNTARILY ACCEPT AND ASSUME ALL SUCH RISKS, DANGERS, AND HAZARDS AND TAKE FULL RESPONSIBILITY FOR YOUR OWN ACTIONS, SAFETY AND WELLFARE; 

  2. CONTACT APPROPRIATE RESPONSE SERVICES. IF YOU ARE HAVING A LIFE THREATENING, A SAFETY ISSUE AND/OR ANY EMERGENCY, YOU SHOULD IMMEDIATELY CONTACT THE APPROPRIATE RESPONSE SERVICES; 

  3. REMOTE ACCESS RISKS TO CONFLIDENTIALITY. THERE ARE RISKS TO CONFIDENTIALITY THAT MAY BE CAUSED BY HAVING REMOTE ONLINE VIDEO/PHONE ICBT SESSIONS (INCLUDING, WITHOUT LIMITATION: (I) POOR QUALITY AUDIO-VIDEO CONNECTION; (II) DELAYS IN EVALUATION OR TREATMENT DUE TO PRODUCT FAILURE; (III) UNAUTHORIZED COLLECTION, USE OR DISCLOSURE OF YOUR PERSONAL INFORMATION DUE TO A SECURITY PROTOCOL BREACH OR FAILURE; AND

  4. NOT TO BE USED FOR EMERGENCIES OR SUICIDAL THOUGHTS OR THOUGHTS OF HARMING OTHERS. TRANQUILITY SHOULD NOT BE USED FOR MEDICAL EMERGENCIES OR IF YOU ARE HAVING SUICIDAL THOUGHTS OR ARE CONTEMPLATING HARMING YOURSELF OR OTHERS. 

RELEASE

EXEMPTION FROM LIABILITY FOR USE AFTER THE TWELVE WEEK PERIOD. TO THE EXTENT PERMITTED BY APPLICABLE LAW, YOU HEREBY REMISE, RELEASE AND FOREVER DISCHARGE INKBLOT, ALL OF ITS AFFILIATES AND ASSOCIATED COMPANIES, AND ALL OF THEIR RESPECTIVE AGENTS, OFFICERS, DIRECTORS, SHAREHOLDERS, SERVANTS, SUCCESSORS, ASSIGNS, EMPLOYEES, FORMER EMPLOYEES (COLLECTIVELY, “INKBLOT RELEASED PARTIES”), FROM ALL LIABILITY, ACTIONS, CAUSES OF ACTION, CLAIMS AND DEMANDS OF EVERY NATURE OR KIND WHICH MAY HAVE BEEN, ARE BEING OR MAY BE MADE OR ASSERTED WITH RESPECT TO, ARISING OUT OF OR IN ANY WAY CONNECTED WITH YOUR ACCESS TO TRANQUILITY AFTER THE FIRST TWELVE WEEKS FROM THE START OF THE PROGRAM. THIS EXEMPTION FROM LIABILITY ALSO INCLUDES LOSS, DAMAGE OR INJURY RESULTING FROM THE NEGLIGENCE OF THE INKBLOT RELEASED PARTIES.

By signing this Informed Consent Form, you acknowledge that you are attending the iCBT training program of your own accord and that you understand that you are free to end the program anytime you wish.

By signing this Informed Consent Form, you understand all of the information contained in it and accept it as the terms and conditions of your participation in Tranquility by Inkblot’s iCBT program (in addition to the Terms of Use, as defined below).

By signing this Informed Consent Form, you understand that these terms are intended to supplement (and are not a replacement for) Inkblot’s terms of use (accessible here: INSERT HYPERLINK), which may be replaced or amended from time to time (the “Terms of Use”). In the event of a conflict between the terms in this Informed Consent Form, and the Terms of Use, this Informed Consent Form prevails to the extent of the conflict. 

You may revoke your consent at any time with verbal and written notice to Tranquility by Inkblot’s Clinical Services Team. If you do not revoke, this consent will expire one (1) year after the date of this authorization.

INDEPENDENT LEGAL ADVICE. YOU AGREE THAT YOU HAVE READ AND UNDERSTOOD THE CONTENTS OF THIS INFORMED CONSENT FORM (INCLUDING, WITHOUT LIMITATION, THE DISCLAIMERS AND RELEASE). YOU HAVE BEEN GIVEN AN OPPORTUNITY TO OBTAIN INDEPENDENT LEGAL ADVICE CONCERNING THE INTERPRETATION AND EFFECT OF THIS INFORMED CONSENT FORM. IN THE EVENT THAT YOU HAVE CLICKED ACCEPT TO THE INFORMED CONSENT FORM WITHOUT THE BENEFIT OF INDEPENDENT LEGAL ADVICE, YOU HEREBY WAIVE THE RIGHT TO RECEIVE SUCH INDEPENDENT LEGAL ADVICE.

By checking this button, I consent to the information provided above, and will be deemed to have signed this Informed Consent Form.