The information that you disclose during counseling is private and protected. Your counselor cannot reveal to others that you are a client, nor can your Counselor share anything that you say during group or individual counseling sessions. You may request your Counselor to share information about you with a third party, before sharing information you are required to complete and sign a Consent to Release Information form.

Any communication by unsecured means (i.e., text messaging and non-encrypted email) will only be used for scheduling appointments or for clarifying questions related to Outpatient services. I understand the risks inherent to insecure Internet transmissions, including any losses or damages.

I agree to participate in Santa Maria's Outpatient Treatment services by means of telehealth services.

I understand that I will receive substance abuse evaluation, treatment and/or education services by a Licensed Chemical Dependency Counselor (LCDC), Licensed Professional Counselor (LPC), or by an LCDC-Intern, LMSW or LPC-Intern under the supervision of a Qualified Credentialed Counselor (QCC).

I agree to call or email my Counselor to schedule an appointment for an one-on-one (individual) session.

I agree to follow the schedule for group counseling.

I agree to complete goals and objectives as specified in the Treatment Plan/ Treatment Plan Review.

I agree that incases of emergency or imminent harm to myself or another person, my Counselor is legally and ethically bound to contact the appropriate authority.

I agree not to post transcripts, videos or any other recordings of individual and/or group counseling sessions online or to distribute by other methods.

I understand that I may request to discontinue a session at any time.

I understand that Santa Maria will make effort possible to structure sessions to ensure effective follow-up care, and I will have th eopportunity to express any concerns I may have.

I understand that the terms and conditions set out in this document is binding for legal purposes.

I understand that all telehealth services may include screening, an admission process, assessment, individual counseling, and counseling in a group setting.

I understand that the same policies applied in a traditional treatment setting apply to telehealth services.

I understand that there will be confidential written records of sessions maintained both at the clinic office in my client file and in the online Clinical Management Behavioral Health System (CMBHS) client record.

I understand that Counselors will provide Outpatient Treatment Programming through audio or video communication utilizing telephone or internet.

I understand there may be potential problems with the use of this new techology. These include but are not limited to: Interruption or disconnection of the audio/video link; an unclear picture or image; and electronic tampering. If any of the above problems occur the visit may need to stop.

I understand the visit may not be equal to a face to face visit with a Counselor.

I understand that the information that I disclose duirng counseling is private and protected.

I understand that I can request that my Counselor share information about me with a third party and that I must complete and sign a Consent to Release Information form for my Counselor to share information with a third party.

I understand that during treatment services (i.e., individual sessions, and group sessions) I must sign into services at a location that provides privacy and limits the possiblities that may violate confidentiality of other clients.  I cannot participate in any session while at locations that are not private (i.e., restaurants, salons, grocery stores, shopping malls etc,).

I received an explanation of the telehealth process.