Self-Management BC Health Coach Program - Participant Consent Form

* 1.

The Self-Management Health Coach Program is one of Self-Management BC's programs. The program is supported by the Institute on Aging and Lifelong Health at the University of Victoria and operates out of the lnstitute's satellite office in Ladner BC. This telephone-based coaching program supports individuals living with chronic conditions to become better self-managers. As part of the program, participants are paired with trained volunteer Health Coaches based on gender, age, shared chronic health condition(s) and/or life circumstances.

In order to maximize your success in the Self-Management Health Coach Program, members of the Health Coach Program Team will request personal information from you. This information will include, but may not be limited to:

• Your name, address, email address and phone number;
• Information regarding your chronic condition(s);
• Barriers you may face in meeting your goals; and
• Goals and actions you want to take to better manage your health.

All information collected will be directly related to your participation in the Self-Management Health Coach Program. The information may be collected in paper and/or electronic form. Paper records will be stored in locked filing cabinets. Electronic records will be password protected. All information will only be accessible to members of the Health Coach Team and Dr. Patrick McGowan, Director, Self-Management BC. Your personal information will only be used for the purposes of the Self-Management Health Coach Program. Information regarding your chronic condition(s), barriers, goals and actions and life circumstances will be permanently destroyed once you have left the program. Paper records will be shredded and electronic records will be deleted.

By completing this consent form, you are confirming you understand that:

• You are agreeing to provide relevant personal information to the Self-Management Health Coach Program;
• All information you provide will be kept strictly confidential and will only be accessible to members of the Health Coach Team and Dr. Patrick McGowan, Director, Self-Management BC;
• Members of the Health Coach Team will use the information you provide for the sole purpose of maximizing your success in the Self-Management Health Coach Program.
  

Please print or save this form for your records.