The Self-Management Frailty Coaching 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 whom are interested in preventing frailty and/or in becoming better self-managers of their frail condition. As part of the program, participants are paired with trained volunteer coaches based on gender, shared chronic health condition(s) and/or life circumstances. In order to maximize your success in the Self -Management Frailty Coaching Program, members of the Frailty Coaching 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 Frailty Coaching 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 Frailty Coaching Team and Dr. Patrick McGowan, Director, Self-Management BC. Your personal information will only be used for the purposes of the Self-Management Frailty Coaching 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 signing this consent form, you are confirming you understand that:
• You are agreeing to provide relevant personal information to the Self-Management Frailty Coaching Program;
• All information you provide will be kept strictly confidential and will only be accessible to members of the Frailty
Coaching Team and Dr. Patrick McGowan, Director, Self-Management BC;
• Members of the Frailty Coaching Team will use the information you provide for the sole purpose of maximizing your
success in the Self-Management Frailty Coaching Program;
• All personal information regarding your chronic condition(s), barriers, goals and actions, and life circumstances will
be permanently destroyed once you have completed the program; and
• If you have any concerns regarding how your personal information is managed or about your participation in the
program, you may contact Dr. Patrick McGowan at 604-940-1273, toll-free at 1-866-902-3767 or pmcgowan@uvic.ca
Please print or save this form for your records.
