Video Counseling Confidentiality Agreement

Please read this document carefully. Your consent provides documentation that you give permission and consent to the East Texas Crisis Center to provide telehealth counseling services to you.
Telehealth counseling services is the delivery of mental health services using secure, real time interactive audio and visual electronic systems where the provider and the client are not in the same physical location. Telecommunication technologies may include smartphones, mobile devices, and/or computers for interactive videoconferencing.
Benefits/Risks: I understand that there are risks to utilizing telehealth counseling services, including but not limited to: risk of technological issues and connection failures, client security and safety being lowered due to client’s environment during session, and increased risk of cyber-hacking. I understand that there are benefits to utilizing telehealth counseling services, including but not limited to: counseling services provided when transportation to counselor’s office may be unavailable, counseling services provided when face-to-face contact is discouraged or unavailable. These risks and benefits cannot be guaranteed for the client.
Client’s Right and Responsibility: Telehealth counseling services are not a good fit for every client! I understand that I have the right to withdraw consent and cease telehealth counseling services at any time if I deem that it is not a good fit for me. If I do consent to receiving telehealth counseling services, I understand that I have a responsibility as the client to create a safe and confidential space during my counseling session. I will need to utilize a space that is free of other people; the environment should be difficult or impossible for people outside of the space to see or hear my interaction with my counselor during the session. I understand that I am responsible for obtaining the necessary equipment, a computer and/or phone with internet access and a webcam and/or microphone, to utilize the telehealth counseling service through https://doxy.me/, which is a HIPAA-compliant platform. I understand that my counselor has the right at any time to determine that telehealth counseling is not appropriate for meeting my needs and will provide referral information if necessary.
Communication Plan Due to Technology Failures: If our telehealth session experiences technological issues or failures, the backup plan will be for me, the client, to contact my counselor via telephone due to safety precautions. The next line of communication will be via email if I am unable to contact my counselor via telephone after experiencing issues with my telehealth service. Please note that all email messages that you exchange with your counselor will become part of your client record. I consent to being contacted via telephone, email, and/or secure videoconference for the purposes of telehealth counseling services and reestablishing connection that may be lost due to technical difficulties.
Emergency Situation: I understand that my counselor is not able to provide 24-hour care and that telehealth counseling does not provide emergency services; my counselor will reply within the next business day except during holidays or times of leave. If I am experiencing an emergency I am encouraged to call 911 or, if I am in need of emergency shelter, the East Texas Crisis Center Hotline at 903.595.5591; or, I may also call 800.333.0358. The crisis Hotline is open 24-hours per day. If I am having thoughts of suicide or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.8255 for free 24-hour support. I understand that if I am experiencing suicidal ideation with a plan and intention, my counselor can contact emergency contact individuals such as 911 if I have signed the ETCC Emergency Contact form giving permission for my counselor to do so.
Confidentiality: Counselors at ETCC operate under the APA and ACA Ethical Principles and strive to ensure strict confidentiality of all communications between family violence counselor, client, and supervisor(s). According to Texas state law and East Texas Crisis Center Policies and Procedures, confidentiality must be breached by a family violence counselor, under the following circumstances: (1) If the client is believed to be a danger to him/herself or to someone else; (2) if child abuse and/or neglect is suspected; (3) if elder abuse and/or neglect is suspected; (4) if abuse and/or neglect of a person with disabilities is suspected; or, (5) if the counselor’s records are subpoenaed by a judge in a court of law. If dangers exist, the proper medical, social, or law enforcement agencies must be notified; and, a conversation will be had between counselor and client if counselor must breach confidentiality. If counselor and client happen to encounter each other in public, counselor will continue to maintain confidentiality and therefore will not initiate contact with client. However, it is okay if the client decides to initiate contact first.
Professional Records: All Texas Health and Human Services Commission related documents, such as forms or any supporting allocation records are retained by the agency for a minimum of seven years after the date of service, or until all litigation, claims, or audit findings are resolved, whichever is longer. After such time, written documentation, such as client files, case notes, and service logs are destroyed by the agency staff using a cross-cut shredder or out-sourcing with a professional shredding company using a cross-cutting method. No records will be released to other clinicians or service agencies without a signed consent from the client.

By checking the box below, I agree that I am giving my counselor permission to initial ETCC required documents on my behalf, (until I am able to initial or sign them myself.)