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Consent - Please Read Consent - Please Read Please read this document carefully. Your consent provides documentation that you give permission and consent to the East Texas Crisis Center to provide telehealth advocacy services to you. Telehealth advocacy services is the delivery of services using secure, real time chat service 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 chat. Benefits/Risks: I understand that there are risks to utilizing telehealth services, including but not limited to: risk of technological issues and connection failures, client security and safety being lowered due to client’s environment during session, and increased risk of cyber-hacking. I understand that there are benefits to utilizing telehealth services, including but not limited to: advocacy services provided when transportation to advocate’s office may be unavailable, advocacy services provided when face-to-face contact is discouraged or unavailable. These risks and benefits cannot be guaranteed for the client. Client’s Right and Responsibility: Telehealth services are not a good fit for every client! I understand that I have the right to withdraw consent and cease telehealth services at any time if I deem that it is not a good fit for me. If I do consent to receiving telehealth services, I understand that I have a responsibility as the client to create a safe and confidential space during my session. I will need to utilize a space that is free of other people; the environment should be difficult or impossible for people outside of the space to see or hear my interaction with my advocate during the session. I understand that I am responsible for obtaining the necessary equipment, a computer and/or phone with internet access, to utilize the telehealth service through https://www.resourceconnect.com, which is a HIPAA-compliant platform. I understand that my advocate has the right at any time to determine that telehealth services are not appropriate for meeting my needs and will provide referral information if necessary. Communication Plan Due to Technology Failures: If our telehealth session experiences technological issues or failures, the backup plan will be for me, the client, to contact my advocate via telephone due to safety precautions. The next line of communication will be via email if I am unable to contact my advocate via telephone after experiencing issues with my telehealth service. Please note that all email messages that you exchange with your advocate will become part of your client record. I consent to being contacted via telephone, email, and/or secure videoconference for the purposes of telehealth advocacy services and reestablishing connection that may be lost due to technical difficulties. Emergency Situation: I understand that my advocate is not able to provide 24-hour care and that telehealth advocacy does not provide emergency services; my advocate will reply within the next business day except during holidays or times of leave. If I am experiencing an emergency I am encouraged to call 911 or, if I am in need of emergency shelter, the East Texas Crisis Center Hotline at 903.595.5591; or, I may also call 800.333.0358. The crisis Hotline is open 24-hours per day. If I am having thoughts of suicide or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.8255 for free 24-hour support. I understand that if I am experiencing suicidal ideation with a plan and intention, my advocate can contact emergency contact individuals such as 911 if I have signed the ETCC Emergency Contact form giving permission for my advocate to do so. Confidentiality: According to Texas state law and East Texas Crisis Center Policies and Procedures, confidentiality must be breached by an East Texas Crisis Center employee, under the following circumstances: (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. I have read and understand the terms; and, I agree to the stated procedures above. I understand the limits to confidentiality and the client’s rights and responsibilities. I hereby give my informed consent for the use of telehealth advocacy services through the east texas crisis center.