Besoin d’aide

Consulting Disclaimer & Waiver for DAPHNE and C.C.S.P.

All services and communication, email or otherwise, delivered by DAPHNE and “Cellule Coordination de Soutien Psychologique” C.C.S.P.), as well as information set forth on the website from DAPHNE USA are meant to help and support you in case from major to minor disaster. However, consultants from DAPHNE and C.C.S.P is not necessary a professional mental health care. If we feel you psychologically stressed to the point that it is interfering with your ability to function, we encourage and suggest you go toward a health professional and we will help you in giving to you some addresses.
In that spirit, by using services from DAPHNE and C.C.S.P., you confirm that you have read and agree to each statement and that you wish to proceed:
• I understand that the consulting services I will be receiving from DAPHNE and C.C.S.P., are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. I also understand that consultants from DAPHNE and C.C.S.P., is not acting as a mental health counselor or a medical professional.
• I understand that consulting is, at present, an unregulated and that consultants from DAPHNE and C.C.S.P. maybe is not licensed by State. I also understand that for all legal purposes, the services provided by the consultants from DAPHNE and C.C.S.P. will be considered to be provided in the Maryland state.
• I understand and agree that I am fully responsible for myself during my meeting, and subsequently, including my choices and decisions.
• I understand that consulting is not a substitute for psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy.
• I understand that all comments and ideas offered by consultants from DAPHNE and C.C.S.P. are solely for the purpose of aiding to find the best way for me to manage this psychological stress situation. I have the ability to give my informed consent, and hereby give such consent to consultants from DAPHNE and C.C.S.P. to assist me in reaching the best advice in this situation.
• I understand that consultants from DAPHNE and C.C.S.P. will protect my information as confidential unless I state otherwise in writing. If I report child, elder abuse or neglect or threaten to harm myself or someone else, I understand that necessary actions will be taken, and my confidentiality agreement limited in this capacity. Furthermore, if consultants from DAPHNE and C.C.S.P. is ordered by a court to provide information or to testify, she will do so to the extent the law requires.
• I understand that the use of technology is not always secure, and I accept the risks of confidentiality in the use of email, text, phone, Skype and other technology.
• I hereby release, waive, acquit and forever discharge the consultants from DAPHNE and C.C.S.P., any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by consultants from DAPHNE and C.C.S.P. as a result of the advice given by consultants from DAPHNE and C.C.S.P. or otherwise resulting from the consulting relationship contemplated by this agreement. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents.

Autorisation de communiquer des renseignements confidentiels

Authorization for Release/Exchange of Confidential Information

RELEASE OF RECORDS INFORMATION: In cases where it appears helpful to obtain or share records and/or information with community resources because the information may reduce the need for seeking or facilitate service provision, it is mentioned which  type of information that will be shared, and the agency/person who has the information. The signature authorizes DAPHNE and C.C.S.P. to obtain the specified records and/or to share information with the specified sources, e.g., authorized health care provider. 

COMMUNICATION DES RENSEIGNEMENTS RELATIFS AUX INFORMATIONS : Dans les cas où il semble utile d’obtenir ou de partager des renseignements et/ou informations avec des ressources communautaires parce que l’information peut réduire le besoin de recherche ou faciliter la prestation de services, il est inscrit le type d’information qui seront partager, ainsi que l’organisme ou la personne qui détient l’information. La signature autorise DAPHNE et les C.C.S.P. à obtenir les dossiers spécifiés et/ou à partager l’information avec les sources spécifiées, par exemple le prestataire de soins de santé autorisé.

Information Requested / Demandée  From / De    To Be Sent To / Envoyé à  
 -General information about you or a relative  
-Information générale vous concernant ou celle d’un proche  
 -DAPHNE (Cellule Coordination de Soutien Psychologique (C.C.S.P.))
– Bénévole et/ou membre de DAPHNE
– Membre et/ou bénévole de DAPHNE
– Responsable Cellule de crise de l’ambassade ou du consulat
  -Medical information about you or a relative -Informations médicales vous concernant ou celle d’un proche-DAPHNE (Cellule Coordination de Soutien Psychologique (C.C.S.P.))
– Bénévole et/ou membre de DAPHNE
– Membre et/ou bénévole de DAPHNE
-Médecins conseils ambassade et/ou consultat

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