FVHH Tele-Mental Heath Support Group Informed Consent

Participant's Name *

First

Last

1.) Informed Consent to TeleMental Health Services with FVHH (Please check each section to confirm your acceptance of this condition) *

I hearby consent to participate in a support group through telemental health with Fox Valley Hands of Hope.

2.) *

I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

3.) *

I understand that there are risk and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

4.)

I understand that due to the nature of attending a support group with other individuals, there is a potential challenge to maintain confidentiality due to disclosures of personal information to others outside the group. In order for all group members to feel secure sharing within the group I acknowledge I will commit to the expectation that each member keeps confidential anything shared by other members during the session.

5.) *

I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

6.) *

I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).

7.) *

I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required

8.) *

I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please email me to discuss since we may have to re-schedule.

9.) *

I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency. I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life-threatening emergency only. This person will only be contacted to go to your location and/or take you to the hospital in the event of an emergency.

In case of Emergency my Address is: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Date / Time

Date

Time

Name (By typing my name in this field I am acknowledging my digital signature of this informed consent) *

First

Last

Parent/Guardian Name (for participants under age 12)

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Last