I understand that the information I provide in this form, including personal and, where applicable, sensitive personal information, will be collected and processed by DMR Psychological Services Inc. for the purpose of registering, assessing, contacting, and providing or coordinating appropriate psychosocial support and related services. I understand that the information will be treated as confidential and will only be accessed or disclosed to authorized persons involved in providing or coordinating the requested service, except when disclosure is required or permitted by law, or when necessary to protect the life or safety of the client or another person.

I understand that if I am referring another person, the information I provide about that person will be used only for the purpose of facilitating contact, referral, and psychosocial support. I confirm that I am authorized to provide the information, or that I am acting in good faith to facilitate support for the person being referred.

I understand that my personal information will be stored securely for the period necessary to fulfill the stated purposes and applicable legal or professional requirements. I understand that, subject to applicable laws and regulations, I have rights as a data subject, including the right to access and correct my personal information and to object to or withdraw consent to processing where applicable.

By submitting this form, I freely and voluntarily consent to the collection and processing of my personal information for the purposes stated above.

You may discontinue answering this form if you do not consent.