Video Counseling Confidentiality Agreement

Video Counseling Confidentiality Agreement Form

For your protection, we need your consent for this services on the platform we link for you, so that you have a secure conversation with your counselor!

Submit this Form for Video Counseling

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Consent - Please Read Consent - Please Read I acknowledge that I have read and understood the above information concerning the types of counseling provided at The East Texas Crisis Center and the potential benefits and risks of counseling. After considering the nature of the counseling offered and possible outcomes, my rights, and my responsibilities, I hereby give my informed consent to receive counseling services at The East Texas Crisis Center. I understand that I may withdraw from counseling at any time. Note: This document contains important information about our professional services and policies. Please read it carefully. When you sign this document, it will represent an agreement between you and the ETCC Counseling Services. A copy of this document is also available at your request. Consent Form and Client Contract The East Texas Crisis Center (ETCC) does not provide primary treatment for severe mental illness or prescribe medication. If those services or interventions are needed, a referral will be made to a more appropriate provider and may be recommended in addition to counseling services at ETCC. If at any time a client at ETCC is deemed to be posing a physical threat of violence or is at risk of harming themselves or others, 911 will be contacted for safety purposes. ETCC is not an emergency treatment facility or a medical facility. Therefore, we do not offer 24/7 emergency services for mental health. If you are experiencing a significant crisis or emergency (i.e. feeling suicidal or homicidal) outside of ETCC’s normal hours of operation, you are advised to participate in your personal safety plan and/or go immediately to the nearest hospital emergency department. If you have an emergency, please call 911. If you are seeking shelter for domestic violence or sexual abuse, please call ETCC’s 24/7 hotline at 903.595.5591 or call 800.333.0358. Fees: Counseling services provided by ETCC are of no cost to the client. Counseling Services: ETCC provides face-to face, telephone, and telehealth services. Our counseling services are based on evidence-based interventions and treatments for trauma. The ETCC counseling program uses a variety of therapeutic approaches dependent upon each counselor’s supplemental certifications and areas of specialization. Benefits/Risks of Counseling: Our services are helpful for someone who is seeking assistance in developing healthy coping skills during or after an abusive relationship or after experiencing sexual abuse. However, there are some risks involved in receiving counseling services at ETCC. These risks may include exposure to painful trauma-related memories, emotions, or thoughts while processing them to reduce the social, physical, or psychological challenges associated with the trauma. While working to achieve this goal, clients might initially feel worse before beginning to feel better— this is a typical occurrence. We encourage you to discuss any concerns or challenges with your ETCC counselor. Expected Course of Counseling: Counseling sessions last approximately 50 minutes. The first appointment will be to identify how to best meet your needs. Upon arrival, you will be provided with paperwork that includes some screening questions to determine the services that may be recommended, including counseling and/or advocacy services. You are free to skip any questions you do not want to answer. We may also provide community resources when appropriate. Typically, clients are seen for 10-15 sessions. However, sessions may be extended based on client/counselor treatment planning. Services for minors will involve a first intake appointment with parents or legal guardians to complete paperwork, obtain proper consent, and determine treatment needs. Following the initial visit, weekly/biweekly sessions will be scheduled. These are scheduled based on counselor availability. Sessions with minors can last anywhere from 30-50 minutes, depending on the child’s age. Nondiscrimination Policy: ETCC welcomes all survivors, regardless of sexual orientation, age, gender, gender identity or expression, race, ethnicity, religion, immigrant status, or ability. Confidentiality: Our policies about confidentiality, as well as other information about your privacy rights, are fully described in the documentation you completed when becoming an ETCC client. ETCC values the confidentiality of our clients and follows the legal and ethical guidelines proposed by both state and federal laws. We do not release any records without your written consent. At times we may consult with other professionals within the agency regarding the management of your case to ensure appropriate and quality care. Every effort will be made to protect your privacy. Limits to Confidentiality: ETCC counselors are legally and ethically obligated to disclose confidential information when the following needs arise: 1) To protect clients from harm to self or others 2) Disclosure or suspected report of abuse/neglect of children, elders, or adults with disabilities 3) Disclosure of abuse by another mental health provider 4) Subpoenas received by state and/or federal courts of law Consultation: In order to provide the best possible services, LPC-Associates/LMSWs consult weekly with their LPC-Supervisor/LCSW-Supervisor and counseling student interns consult weekly with ETCC’s site supervisor, Ana Barnson, MA, NCC, LPC-S. The discussions are general in nature, and identifying information is not disclosed during consultations. If a situation or concern arises in which an LPC-Associate/LMSW/counseling student intern does not have sufficient knowledge about (or per your request to be referred to a different counselor), you may be referred to another professional specialized in that area to provide you with the best possible services or treatments. Records: We are required to keep appropriate records of the services we provide. Records are kept for 7 years after the last date of services for clients with histories of domestic violence and 10 years for clients with histories of sexual assault. All records are kept confidential and ETCC adheres to the Family Violence Prevention and Services Act (FVPSA) and the Violence Against Women Act (VAWA) procedures and guidelines. Records will not be disclosed without your authorization unless one of the four exceptions listed above occurs. If you would like a report sent to another provider, we require a signed release of information and we recommend you review and discuss the case notes with your ETCC counselor prior to release. ETCC does report outcomes to funders. However, all information is de-identified to protect your confidentiality. Professional Relationship: The professional relationship between client and counselor requires high standards of moral, ethical, and appropriate conduct on the part of your ETCC counselor. Boundaries must be upheld and relationship must be confined to ETCC services. ETCC staff cannot be expected to be involved in any friendship or social relationship outside of our services. If you choose to engage in social media with ETCC, ETCC staff cannot personally connect with you on social media. This is to protect the professional relationship and client confidentiality. Counselors are not able to provide legal advice. It is the client’s responsibility to seek legal advice or counsel for any questions about legal issues. Electronic Communication: Email and other forms of electronic messages provide convenient methods of communication. Please be advised that these methods, in their typical form, are not confidential means of communication. Therefore, ETCC will use email communication and text messaging only with your permission and only for administrative purposes. If you authorize these methods to communicate with ETCC, we cannot guarantee secure or error-free communication. You may revoke your authorization in writing at any time. Appointment Cancellation, No-Show, & Late Arrival Policies: Appointments last approximately 50 minutes. Your appointments are very important to us. When an appointment is scheduled, that time has been specifically reserved for you and if you forget, cancel, or change your appointment without a 24-hour notice, we miss the opportunity to fill that appointment slot with another person in need of services. We sincerely appreciate your assistance and cooperation with the policies below, as this may allow us to better schedule appointments for all clients. · If you need to cancel an appointment, please give us at least 24-hour notice. If you do not provide us with 24-hour notice, please consider that we cannot secure the same availability for subsequent appointments. To cancel or reschedule your appointment, please call our front desk (903.509.2526) or reach out to your counselor. · If you have three no-shows or non-emergency late cancellations, you will need to wait 3 months to be able to schedule another appointment. · If you arrive 15 minutes or more after your scheduled time, the appointment will be canceled and rescheduled for the next available time. · If at any time an appointment must be canceled by the East Texas Crisis Center due to travel, weather, illness, or emergency, we will reschedule you for the next available appointment. While counselors prioritize prompt communication with ETCC clients, it may take 24-48 business hours for counselors to reply via email or telephone to clients. Services to Minors: When making an appointment for a minor, consent for services must be given by the legal parents, managing conservators, guardians, or a person designated by the court to have the authority to consent prior to initiating services with the minor. An initial appointment is scheduled with the parent/caregiver to obtain the proper consent. If the minor is named in a custody agreement, divorce decree or court order, the ETCC counselor must obtain and review the most updated copy and keep it in the minor’s record. Under the Texas Family Code, a minor can consent for services for themselves if one of the following conditions is present: suicide prevention, chemical addiction or dependency, sexual, physical, or emotional abuse, pregnancy, or if a minor is emancipated or is in active duty with the armed services of the U.S. The minor’s counselor will need to inform the minor’s parent/caregiver of the services provided with or without the minor’s consent. Services to minors are to support the healing process after domestic violence or sexual assault and to support the non-offending family with immediate crisis. We do not make custody evaluations nor provide expert recommendations regarding possession of or access to minors in court proceedings. Confidentiality Regarding Minors: Because confidentiality is crucial in developing a positive therapeutic relationship, the child’s counselor will provide the parent/caregiver general information about the services provided and the minor’s progress. Exceptions to this policy are when there is an imminent danger to the child or someone else. As a parent/caregiver, you are expected to be involved in the process and participate in the treatment planning. Failure to do so may result in termination of counseling services. Telephone/Telehealth Counseling Services: Distance counseling services refer to the delivery of counseling services using interactive technologies (use of audio, video, or other electronic communications) between a counselor and a client who are not in the same physical location. As a client receiving telephone/telehealth counseling services, I understand and consent to the following: Privacy & Confidentiality Maintaining client confidentiality is crucial at ETCC. While the internet may seem private, online counseling poses greater privacy risks than in-person sessions. The client is responsible for understanding the potential risks of confidentiality being breached through unencrypted email, lack of password protection, or leaving information on a public access computer. To better ensure privacy, we recommend that you utilize a private space. Recording sessions without both client and counselor consent is strictly prohibited. Please also be aware that we cannot guarantee confidentiality for telephone sessions as phone lines could be unsecure. Benefits & Limitations Distance counseling services are provided by technology (including but not limited to phone, video, and email) and may not involve direct face-to-face communication. There are potential benefits and limitations to these services (e.g. limits to client confidentiality). Distance counseling may also differ in effectiveness from face-to-face sessions. If an ETCC counselor believes face-to-face counseling would better serve a client, a referral will be made to a local counselor. Technology Requirements Clients are responsible for obtaining the necessary equipment, such as a smartphone or a computer with internet access, a webcam, and/or microphone to utilize telehealth counseling services through Doxy.me. Doxy.me is a HIPAA-compliant platform. Clients will need access to and familiarity with the appropriate technology to participate in telehealth counseling services provided. Counselors will assist clients with this process as needed. Laws & Standards The laws and professional standards that apply to face-to-face counseling services also apply to telephone/telehealth services. Complaints: If a concern arises during counseling or if you should ever have a complaint, we ask that you speak to your ETCC counselor and/or their supervisor first to try to resolve the issue. If you cannot resolve the issue, your counselor will provide you with referrals to other counseling professionals in your community that will be able to assist you. If you believe your counselor’s conduct as an LPC/LPC-Associate/LMSW is in violation of your rights under the law, you may send a written complaint to Texas Board of Examiners of Professional Counselors/Texas State Board of Social Worker Examiners, Complaints Management and Investigative Section, P.O. Box 141369 Austin, Texas 78714-1369 or call 800.821.3205.