Telehealth Form

Children's
ADVOCACY CENTER
OF LOWNDES COUNTY
Telebehavioral & Telemental Health Policy
Tele-health is the delivery of healthcare services using interactive technologies (use of audio, video, or other electronic communications) between a therapist and a client who are not in the same physical location. The interactive technologies used in telebehavioral & telemental health incorporate network and software security protocols to protect the confidentiality of client information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. The laws and professional standards that apply to in-person services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent. All existing laws regarding client access to mental health information and
copies of mental health records apply. There is no permanent video or voice recording kept of
the telemental health service sessions.
Telemental health services will be provided by only licensed clinicians.
The platform we will use at this time is Zoom. Zoom's solution and security architecture provides end-to-end encryption and meeting access controls so data in transit cannot be intercepted. Zoom does not have access to identifiable health information and we protect and encrypt all audio, video, and screen sharing data.
The Children's Advocacy Center reserves the right to change platforms or technology at its discretion to best insure the security, confidentiality, and portability of these services.
There are benefits and limitations to this service. The benefits include:
enhancing access to therapeutic services that are unavailable in person because of geographical distance, clients' disabilities, illnesses, or extreme circumstances real-time monitoring of clients' status, when appropriate being able to respond to clients rapidly enhancing access to services because of clients' scheduling challenges ease of communication reducing the frequency of clients' travel to obtain therapeutic services
potential for technology failure and interruption of services potential for confidentiality breaches
In an effort to promote a more confidential environment, The Children's Advocacy Center recommends the use of white noise machines or apps or headphones during the delivery of
Participation is completely voluntary and will only be offered to clients who are unable to come for in-person sessions.
If you choose to use telebehavioral & telemental health services, please initial next to each statement:
I understand that the exchange of information will not be direct and any paperwork exchanged will likely be provided through electronic means.
I understand that the exchange of information will not be direct and any paperwork will likely be provided through electronic means.
Initial Here
I understand that it is required that I use my own technology equipment in a room by myself or with a caregiver during all telehealth sessions. I understand that I will be provided a passcode by my therapist, and I will be required that passcode at the beginning of every session to confirm my identity.
Initial Here
I understand that my therapist will provide me a link to the video conference via email. I expected to login to the conference within ten minutes of my appointment time. I will reach the therapist if I am having issues with my technology.
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I acknowledge that if I am facing or if I think I may be facing an emergency situation could result in harm to me or to another person; I am not to seek a telebehavioral Instead, I agree to seek care immediately through my own local health care practitioner or the nearest hospital emergency department or by calling 911 or by calling the crisis center.
Initial Here
I understand that I may decline any telebehavioral health services at any time without jeopardizing my access to in person care, services, and benefits. If a need for direct, in services arises, I will contact my therapist for an in person appointment. If my health therapist is not in my geographical area, he/she will provide me with a list practitioners in my area that I may contact. I understand that an opening with another may not be immediately available.
Initial Here
I understand that if technology fails during our session, my therapist will call me provided number to continue our session. If possible, video conferencing will be
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I understand that my therapist has to ensure my safety. If my therapist believes that I unsafe or in need of immediate physical contact, they can reach out to my emergency (including local physician, crisis hotline, trusted family, and friends). In the event of emergency, below are three people my therapist may contact
Initial Here
Name
Number
Name
Number
Name
Number
I unconditionally release and discharge The Children's Advocacy Center, its affiliates, and employees from any liability in connection with my participation in the remote therapeutic session(s)
Initial Here
I unconditionally release and discharge The Children's Advocacy Center, its affiliates,
agents, and employees from any liability in connection with my participation in the remote therapeutic session(s)
I have read this document carefully and fully understand consent for this treatment delivery method along with the benefits and risks. I have had the opportunity to ask any questions I have and have received satisfactory answers. With this knowledge, I voluntarily consent to participate (or for my child to participate) in the telebehavioral sessions provided by my therapist at The Children's Advocacy Center.
Printed name of caregiver or client, if 14 years old or older
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of caregiver or client, if 14 years old or older
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Therapist
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Children's

ADVOCACY CENTER

OF LOWNDES COUNTY