Dialogue Consent Form - In Person EAP

Last Updated: July 10, 2023

The purpose of this form is to obtain your consent for Dialogue to provide you with In-Person Employee Assistance Program (EAP) services. This consent is separate from any other consents provided to Dialogue under our other services, found here https://www.dialogue.co/en/consent-form.

You must read and be sure that you fully understand the relevant sections of this consent form, and the linked Terms of Use, and the Privacy Policy that applies to your country of origin before using Dialogue’s secure platform (the “Platform”), made available through Dialogue’s application for mobile devices and through a web browser (collectively, the “App”) or through our telephone services. If you have any questions, please contact us at hello@dialogue.co. 

About In-Person EAP

In-Person EAP is a distinct service from Dialogue’s Telemedicine services. Dialogue facilitates your request to be referred for in-person EAP services. Dialogue will assess your request and available  EAP providers in our network that meet your needs. Please note that Dialogue is providing a referral service to the  EAP providers who are responsible for your personal health information and respect the legislative and professional requirements that govern the collection and processing of that information. The independent EAP provider will have their own Privacy Policy and consent forms as to the services they provide directly to you. 

In order to provide you with the requested services and associated system management tasks by Dialogue, our care team (which includes health services providers and supporting staff) may have to collect health information from you. Collection of health information for this purpose is authorized under the Applicable Privacy Laws (as this term is defined in our Privacy Policy).

If you have any questions about the collection and use of your personal information or personal health information, or if, at any time, you wish to withdraw your consent, please refer to Dialogue’s Privacy Policy or contact Dialogue’s Chief Privacy Officer at privacy@dialogue.co. Please note that if you withdraw your consent to the collection and use of your personal information and personal health information, we may not be able to provide you with a particular product, service, or Consultation and you may not be able to access the Platform, the Website or the App anymore. We will explain the impact to you at the time to help you with your decision.

Consent

By agreeing to this Consent Form, you indicate that you:

• Understand and consent to the collection, use and sharing of your personal information including your personal identification, medical, and other personal information, in order to provide you with the In-Person EAP Services offered through Dialogue. 

• Understand and consent to Dialogue collecting personal information from the independent EAP providers that provide you with the In-Person EAP services for billing and record management purposes. 

• Understand and consent to Dialogue periodically contacting you by telephone or electronic communication to verify the In-Person EAP services received.  

• Understand that the collection, use and disclosure of your personal information will be in accordance with Applicable Privacy Laws and our Privacy Policy that you confirm you have read and understood.

• You understand that this consent is valid for the duration of your use of the Services and that you may withdraw it at any time by writing to privacy@dialogue.co.

• You have read and understood this Consent form and you consent to the processing of your personal information, including health information as provided herein.