Intake Request Form

Confidentiality:
You have the right to privacy and we will protect any personal information that we collect by
following Canada’s privacy laws. Information will be collected to assist in providing services to you as
well as for collecting statistics. Personal information will be accessed by Burnaby Neighbourhood
House (BNH) - Settlement Program staff, government designates, and our funder, Immigration,
Refugees, and Citizenship Canada (IRCC). You will only give us personal information about other
persons (children, family members) that you are allowed to give. BNH’s Settlement Programs will
never rent, sell, or distribute personal client information without your written consent. Your data is
securely kept in accordance with IRCC’s standards.

Limits to Confidentiality:

• As required by the funder, Immigration, Refugees, and Citizenship Canada (IRCC).
• When it is required by law or by court order.
• When there is reasonable grounds to believe that a client will harm themselves or another
  person.
• When there is reasonable grounds to believe that a child is being harmed or at risk of
  imminent harm.

I understand that this is a free service and that my participation is voluntary. I can leave the program
at any time and continue to receive other BNH services without penalty. I have the right to request to
see my file. By signing below, I indicate that I understand and accept this agreement.