Video Counseling Confidentiality Agreement

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Consent - Please Read Consent - Please Read I have read and understand the terms; and, I agree to the stated procedures above. I understand the limits to confidentiality and the client’s rights and responsibilities. I hereby give my informed consent for the use of telehealth advocacy services through the east texas crisis center. 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. The East Texas Crisis Center (ETCC) does not offer long-term therapy, 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. At any time, a client at ETCC is deemed to be posing a physical threat of violence or is at risk for harming themselves or others, 911 will be contacted for safety purposes. The East Texas Crisis Center is not an emergency treatment facility or a medical facility; therefore, we do not offer 24-hour emergency services for mental health. If you are experiencing a significant crisis or emergency (i.e. suicidal or homicidal), outside the normal hours of operation, you are advised to participate in your personal safety plan and/or go immediately to the nearest hospital emergency department. Fees: Counseling services provided to clients of the East Texas Crisis Center 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 trauma-informed interventions and research-based treatments for trauma. The ETCC counseling program uses a variety of therapeutic approaches, including but not limited to: Trauma Focused - Cognitive Behavioral Therapy, Solution-Focused Brief Therapy, Narrative Therapy, Bilateral Stimulation (EMDR), Cognitive Processing Therapy (CPT), Sandtray intervention, body-based interventions, and Non-directive and Directive Playful Interventions. Not each ETCC counselor/counselor intern is able to provide all of the aforementioned therapeutic approaches; therapeutic interventions used depend on the counselor’s supplemental certifications. Typically, clients are seen for 10-15 sessions; however, sessions can be extended up to five (5) or more based on client/counselor treatment planning. The ETCC counselor/counselor intern will assist you in identifying treatment goals and developing healthy coping skills. You have the right to be informed of the progress toward your mental health goals. Benefits/Risks: 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 the ETCC. These 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. In working to achieve this goal, clients might feel worse for a period of time before beginning to feel better—this is a typical occurrence. We encourage you to discuss any challenges or concerns with your ETCC counselor/counselor intern. Expected Course of Therapy: ETCC counselor/counselor intern provide around 10 – 15 counseling sessions. Appointments last for approximately 50 minutes. The first appointment will be to identify how to best meet your needs. Upon arrival or by email, you will be provided with paperwork/links that include some screening questions to determine the services that may be recommended, including individual, family, or group therapy and/or advocacy services, or medical services. You are free to skip any questions you do not want to answer. We may also provide community resources when appropriate. Services for minors will involve a first intake appointment with parents or legal guardian to complete paperwork, obtain proper consent, and determine the treatment needs. Following the initial visit, weekly/every other week sessions will be scheduled. These are scheduled based on therapist/counselor intern availability 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. We remind you that the 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 of Confidentiality: ETCC Counselors/counselor interns 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, and adults with disabilities; 3.) Disclosure of abuse by another mental health provider; 4.) Subpoenas received by state and/or federal courts of law Confidentiality regarding minors: Because confidentiality is crucial in developing a positive therapeutic relationship, the child’s provider will provide 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. Parents/caregivers are expected to be involved in the process and participate in the treatment planning; and, failure to do so may result in termination of counseling services. Electronic Communication: Email, text, 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, The 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 can revoke your authorization in writing at any time. Professional Relationship: The professional relationship between client and counselor/counselor intern requires high standards of moral, ethical, and appropriate conduct on the part of your ETCC counselor/counselor intern. Boundaries must be upheld and the relationship is confined to the ETCC services. ETCC staff cannot be expected to be involved in any social relationship or friendship outside our services. In addition, if you choose to engage in social media with The East Texas Crisis Center, ETCC staff cannot personally connect with you on social media. This is to protect the professional relationship and your confidentiality. Therapist/counselor interns are not able to provide legal advice. It is the client’s responsibility to seek legal advice or counsel for any question about legal issue Contact and Emergency Situation: The East Texas Crisis Center is not an emergency treatment facility or a medical facility; therefore, we do not offer 24-hour emergency services for mental health. If you are experiencing a significant crisis or emergency (i.e. suicidal or homicidal), outside the 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 or if you are seeking shelter for domestic violence or sexual abuse, please call the East Texas Crisis Center Hotline at 903.595.5591; or, call 800.333.0358. The Hotline is open 24-hours per day if you are needing shelter. 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. All records are kept confidential and the 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 client’s 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 records and we recommend you review and discuss the case notes with your ETCC Therapist/Counselor intern. The ETCC reports outcomes to funders; however, all information is de-identified to protect your confidentiality. Nondiscrimination policy: The East Texas Crisis Center welcomes all survivors, regardless of sexual orientation, age, gender, gender identity or expression, race, ethnicity, religion, immigrant status, or ability. 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 parents/caregiver to obtain the proper consent. It is our policy that ALL legally authorized persons representing the minor will need to sign the consent for services. If the minor is named in a custody agreement, divorce decree or court order, we 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 active duty with the armed services of the U.S. The child’s provider will need to inform the minor’s parents of the services provided with or without the minor’s consent. Services to children are for supporting the minor’s healing process after domestic violence or sexual abuse 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 child in court proceedings. Appointment Cancellation, No Show, and Late Arrival Policies: Appointments last for 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 24-hour notice, we miss the opportunity to fill that appointment with another person in need of services. We sincerely appreciate your assistance and cooperation with the following policies, as this may allow us to better schedule appointments for all clients: 1. If you need to cancel an appointment, please give us at least 24-hour notice. If you do not provide us with a 24- hour notice, or if you do not show up for a scheduled appointment, please consider that we cannot secure the same availability for subsequent appointments. You may run the risk of having to wait for an opening in your counselor’s schedule. To cancel or reschedule your appointment, please call our front desk or reach out to your therapist. 2. If you have 3 no-shows or non-emergency late cancellations, you will need to wait 3 months to be able to schedule another appointment. 3. If you arrive 15 minutes or more after your scheduled time, the appointment will be canceled and rescheduled for the next available time. 4. 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. Notice that while counselors/counselor interns prioritize prompt communication with ETCC clientele, it may take 24-48 business hours for a counselor/counselor intern to reply via email or telephone to clients. Telehealth/ Phone Counseling Services: As a client receiving Telehealth/Phone Counseling services, I understand and consent to the following: Distance counseling services refer to the delivery of counseling services using interactive technologies (use of audio, video, or other electronic communications) between a therapist/counseling intern and a client who are not in the same physical location. Privacy and Confidentiality • Maintaining client confidentiality is extremely important. The counselor/counselor intern will take extraordinary care and consideration to prevent unnecessary disclosure. Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than in person. 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 in a library or internet café. To better ensure privacy, we recommend that you utilize a private space. Recording the session without consent of both the client and the counselor/counselor intern is strictly prohibited. For phone sessions, please be aware that we cannot guarantee confidentiality as phone lines could be unsecured. • In addition, the clients understand that distance counseling services may not yield the same results nor be as effective as face-to-face services. The clients understand that if their counselor/counselor intern believe the clients would be better served by another form of psychotherapeutic service (e.g. in-person), the clients will be referred to a counselor in their area who can provide such service. • The interactive technologies used in distance counseling incorporate network and software security protocols to protect the confidentiality of client information transmitted via electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. Benefits & Limitations: • This service is provided by technology (including but not limited to video, phone, text, apps and email) and may not involve direct face-to-face communication. There are potential benefits and limitations to these services (e.g. limits to patient confidentiality). Technology Requirements: • Clients are 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. • Clients will need access to, and familiarity with, the appropriate technology in order to participate in the service provided. The therapist/counseling intern will assist the client in this process. For video counseling, clients will need to use a webcam or smartphone during the session. Laws & Standards: • The laws and professional standards that apply to in-person counseling services also apply to telehealth services. Consultation: When working with a Counselor Intern or LPC-Associate, in order to provide the best possible services, counselor interns will consult weekly with ETCC site supervisor Ana Barnson, MA, NCC, LPC and LPC-Associates will consult weekly with their LPC-Supervisor. The discussions are general in nature, and counselor interns/LPC-Associates will not disclose any identifying information during a consultation. If a situation or concern arises in which the counselor intern/LPC-Associate does not have sufficient knowledge of or per your request to be referred to a different counselor, they may refer you to another professional specialized in that area to provide you with the best possible services or treatments. Complaints: If you have a complaint or concern, we hope that you would speak to your ETCC counselor/counselor intern or their supervisor first to try to resolve the concern. If you should ever have a complaint or an issue arises during counseling, please feel free to bring this up with your counselor/counselor intern so that the issue can be discussed. If you cannot resolve the issue, your counselor/counselor intern will provide you referrals to other counseling professionals in your community that will be able to assist you. If you believe your counselor’s/LPC-Associate’s conduct as an LPC is in violation of your rights under the law, you may send a written complaint to Texas Board of Examiners of Professional Counselors, Complaints Management, and Investigative Section P.O. Box 141369 Austin, Texas 78714-1369 or call 1-800-942-5540. I acknowledge that I have read and understood the above information concerning the type 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.

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Permission to Initial Permission to Initial Yes, I permit ETCC to initial for me. 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.)