CONSENT TO PARTICIPATE IN DISTANCE COUNSELING

CONSENT TO PARTICIPATE IN DISTANCE COUNSELING

1. I understand that I am being asked to consent to professional distance
    counseling for myself and/or my child/guardian recipient.

2. It has been explained to me how tele-video/telephonic distance counseling
     works.

3. I understand that receiving tele-video/telephonic distance counseling is not the
    same as in-person counseling due to the fact that I will not be in the same room
    as my counseling professional.

4. I understand that there are potential barriers/risks to this technology, including but not limited to:

·         Information transmitted may not be sufficient (e.g., poor connectivity) to allow for appropriate decision making by the counseling professional.

·         Security protocol may fail, causing a breach of privacy with my confidential counseling session information.

·         Tele-video/Telephonic distance counseling may not allow for the same type of clinical assessment that can be done with in-person counseling, which could result in clinical assessment errors.

·         I understand that my counseling professional or I can discontinue the distance counseling session if it is felt that the tele-video/telephonic connections are not adequate for the situation or if it is felt that I require in-person evaluation and/or in-person counseling sessions.

5. I understand that there are benefits to using tele-video/telephonic counseling, including but not limited to:  

·         Convenience for the individual seeking counseling

·         Increased accessibility to counseling where a counseling professional would normally not be available and/or accessed in-person

·         Ability to see a counseling professional more rapidly

·         Potential for increased comfort when talking with a counseling professional over tele-video and/or telephone versus in-person

6. I have had the alternatives to tele-video/telephonic distance counseling explained to me, and I
    am choosing to participate in tele-video/telephonic distance counseling.

7. I understand that none of the tele-video/telephonic sessions will be recorded in any way.

CLIENT AGREEMENTS FOR DISTANCE COUNSELING

Technology: I agree that I have experience with using technology and that I will maintain up-to-date Internet services on my chosen device for connection. I agree that I will install and use Zoom for distance counseling.

Privacy: I agree to maintain a private space for the counseling session to take place with little/no disruptions.

Location: I agree that my child and I will be physically within the state of Texas during the distance counseling session. If I am not within the state of Texas, the session will be rescheduled.

Recording: Grayson County Children’s Advocacy Center will not record any distance counseling sessions. I agree that I will NOT use any technology to record a distance counseling session.

Adult Presence: I agree that I will stay physically onsite during the distance counseling session or I will designate a responsible adult over the age of 18 years old to stay on site during my child’s session.

Emergency Contact: I agree that I will provide an emergency contact name and phone number who is either on site of the distance counseling or within 25 miles of the client’s location.

Email Authorization: I give permission for Grayson County Children’s Advocacy Center to send any communication via e-mail, which can include, but not limited to resources,graduation pictures, forms, etc. By agreeing, I also understand that Grayson County Children’s Advocacy Center is not held liable for any breach of confidentiality due to email communication.

I have read this document carefully and understand the benefits and risks of the televideo/telephonic distance counseling.  I have had my questions regarding the process explained to me, and I hereby consent for my child/guardian recipient and/or myself to participate in tele-video/telephonic distance counseling under the terms described herein.