Consent Form for Virtual Group Services

Please read this document carefully. Your consent provides documentation that you give permission and consent to the East Texas Crisis Center to provide Virtual Group services to you.

Virtual Group services is the delivery of 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.

Please fill out the boxes below to receive this services!

  • Virtual group services are not a good fit for every client!
    (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.
    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.
  • Date Format: MM slash DD slash YYYY