Telehealth Consent

Please correct the errors described below.

Still Waters Family Counseling TAC # SWFC1

Informed Consent for Technology Assisted Counseling and Supervision

This document will explain the process of technology assisted counseling and the various risks and benefits of this with safeguards and procedures to address these. Please read this completely and print and sign your name.

Technology Assisted Counseling is being made available by all our counselors in our current State of Emergency re: COVID-19. Once the Emergency is lifted, only Peter Duncan and Curt Matzenbacher will be able to continue providing Technology Assisted Counseling.

Counseling Benefits and Risks

Potential benefits of technology-based mental health services can include less time restrictions through means of connection (email communication), time to consider responses, reduction of inhibition of being in person (distance), inclement weather avoidance, child-care restrictions can be removed, ability to work more easily around job obligations. Text-based chat has the benefit of convenience, the feeling of reduced scrutiny from the counselor, and time to ponder and compose a response with review of chat log or reference. Video-based chat allows for counseling to occur from anywhere within the state of services with internet connection and available hardware.

Potential risks can include misunderstandings through technology use, effectiveness of technology utilized (availability and potential service limits from area to area; comfort level and familiarity of client with technology being used; potential issues of breaks in service), with confidentiality for client (securing patient information; missending of information; breach or hack of access; information left on public access computer; public access by others to see or hear communication via electronic device screen or microphone; lack of phone encryption).

Your counselor or supervisor has selected several safeguards to address these risks to provide the highest possible security and confidentiality of the content of your sessions or communications. Password(s) will be created and maintained by the client or supervisee to protect communication and access and to verify identity. Client or supervisee will also be responsible to maintain any additional safeguards for devices they will use to communicate or use in therapy or supervision (keeping passwords secret, limiting access to devices used, and maintaining security at access points used).

Should there be disconnection or disruption in technology services being used (internet, email), the client or supervisee should call the therapist at the number provided above.

Misunderstandings may occur with electronic means of communication when sometimes nonverbal cues are lacking or misinterpreted. Counselors often use observations of body language, tone and volume and eye contact to gather information and understand more about their clients. If you have not used technology-based
counseling or supervision before, please have patience with the process and clarify information you think your counselor or supervisor has not understood well. Be patient if your counselor asks periodically for clarification as well.

Technology-assisted counseling may not be appropriate for some clients with concerns about technology or internet service use, those with active suicidal or homicidal thoughts and those who are experiencing active manic or psychotic symptoms. Alternatives to technology therapy would be face-to-face mental health services in your area. The counselor can assist with referrals for these local options to help locate services that would be more practical or beneficial for you.

Records

The counselor will maintain records of online counseling services. These records can include reference notes, copies of transcripts of chat and internet communication and session summaries. These records are confidential and will be maintained for five years as required by applicable legal and ethical standards according to the American Counseling Association and the Arkansas Board of Examiners in Counseling. The client will be asked in advance for permission before any audio or video recording will occur on the counselor’s end. Electronic files will be protected by encryption.

Confidentiality

Maintaining client confidentiality is extremely important to your counselor and it is his responsibility to take proper care and consideration to prevent unnecessary disclosure to others. Information about the client will only be released with his or her permission, with the exceptions of the following:
 The counselor believes that someone is seriously considering harm to self
 The counselor believes that someone intends to cause harm to others
 The counselor suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult
 If the client provides or signs a written request for the release of information

If the client is a minor, their parent/guardian will need to provide consent for counseling and for release of any information.

Privacy of the Counselor

Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than in person. The client is responsible for securing their own computer hardware, internet access points, chat software, email and passwords. The counselor has a right to his or her privacy and may wish to restrict the use of any copies or recordings the client makes of their communications. Clients must seek the permission of the counselor before recording any portion of the session and/or posting any portion of said sessions on internet websites such as Facebook or YouTube.

Procedures

The counselor might not immediately receive an online communication or might experience a local problem with technologies used. If the client is in a state of crisis or emergency, the counselor recommends contacting a crisis line or an agency local to the client. Clients may utilize the following crisis hotlines: • 1-888-274-7472 • 1-800-SUICIDE • 1-800-273-TALK • For the Deaf: 1-800-799-4TTY

Your counselor will also work with you to identify local resources based on your location.

Please install and test software used for sessions prior to session time.

Payments

All payments will be processed through our office. The client is required to have a credit or debit card on file unless other arrangements have been made.

Disconnection of Services

If there is ever a disruption of internet services, the client may try to reach the counselor by phone at 479.263.7602.

All technology assisted counseling or supervision will comply with the Arkansas Laws as stated by the Arkansas Board of Examiners in Counseling and Marriage and Family Therapy. Any questions or concerns can be directed to this board by phone at 501-683-5800 or through their website at http://abec.arkansas.gov.

Still Waters Family Counseling TAC # SWFC1

Informed Consent for Technology Assisted Counseling and Supervision

I understand the information conveyed in the document TAC # SWFC1 as it relates to Technology Assisted Counseling from Still Waters Family Counseling. I have been given opportunity to ask questions about the document. The document explained the process of technology assisted counseling and the various risks and benefits of this with safeguards and procedures to address these.

As a reminder, Technology Assisted Counseling is being made available by all our counselors in our current State of Emergency re: COVID-19. Once the Emergency is lifted, only Peter Duncan and Curt Matzenbacher will be able to continue providing Technology Assisted Counseling due to specialized training normally required.

To show your agreement to these policies, please print and sign your name below:

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