Virtual Support Group Services

First Name

Initial Last

Email Address

Date

Can we respond to you by email? Can we respond to you by email? Yes No

Benefits/Risks Benefits/Risks I understand that there are risks to utilizing virtual group 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 virtual group services, including but not limited to: advocacy services provided when transportation to advocate’s office may be unavailable, advocacy services provided when face-to-face contact is discouraged or unavailable. These risks and benefits cannot be guaranteed for the client.

Client's Rights and Responsibility Client's Rights and Responsibility I understand that I have the right to withdraw consent and cease services at any time if I deem that it is not a good fit for me. If I do consent to receiving virtual group services, I understand that I have a responsibility as the client to create a safe and confidential space during my 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 advocate 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 virtual group service through link provided by facilitator, which is a HIPAA-compliant platform. I understand that my facilitator has the right at any time to determine that virtual groups are not appropriate for meeting my needs and will provide referral information if necessary.

Emergency Situation Emergency Situation I understand that my advocate is not able to provide 24-hour advocacy and that the virtual group Facilitator does not provide emergency services; 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 available 24-hours. 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 advocate can contact my listed emergency contact individuals such as 911 or others. I have signed the ETCC Emergency Contact form giving permission for my advocate to do so.

Confidentiality Confidentiality I understand that according to Texas state law and East Texas Crisis Center Policies and Procedures, confidentiality must be breached by an East Texas Crisis Center employee, under the following circumstances. (1) If child abuse and/or neglect is suspected; (2) if elder abuse and/or neglect is suspected; and/or (3) if abuse and/or neglect of a person with disabilities is suspected. If dangers exist, the proper medical, social, or law enforcement agencies must be notified; and, a conversation will be had between advocate and client if advocate must breach confidentiality.

Virtual Group Confidentiality Virtual Group Confidentiality I agree that the location of the group meetings and the names, identities, and other personal information of group participants will not be disclosed to anybody outside the group, at any time during or after the group. I understand that screenshots, saving chats, or recording groups is prohibited. I agree that when attending a virtual group, I will attend in a safe private location. Headphones are encouraged to ensure privacy for all attendees. If attending virtual group using public Wi-Fi, I will inform the group facilitator before attending. I will not share any group links with others. If someone would like access to the group, they must receive the access link from the group facilitator. I understand if I breech group confidentiality the facilitator has the right to remove me from the virtual group and prohibit attendance to future virtual groups.

Consent Consent 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.