The following information is to be completed by the person being served or the person’s authorized representative/parent.
The purpose of this document is to inform you, the client, about many aspects of online counseling services: the process, the counseling, the potential risks and benefits of services, safeguards against those risks, and alternatives to online services. Please read this entire document, sign, and return.
Process
1) Possible misunderstandings: The client should be aware that misunderstandings are possible with telephone and video-based modalities such as Doxy.me because nonverbal cues are relatively lacking. Even with video webcam software, misunderstandings may occur due to connection problems causing image delays or less than optimal image quality. Counselors are observers of human behavior and gather much information from body language, vocal inflection, eye contact, and other non-verbal cues. If you have never engaged in online counseling before, please have patience with the process and clarify information if you think your counselor has not understood you well. Also, please be patient if your counselor asks for periodic clarification. All sessions and messaging are in English.
2) Turnaround time: Using asynchronous (not in "real time") communication such as Doxy.me entails a potential of “lag” of response. If the client is in a state of crisis or emergency, the counselor recommends the client contact a crisis line or an agency local to the client. Clients may also utilize 1-800-SUICIDE or 1- 800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY).
3) 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. Your counselor has chosen to use Doxy.me as the software provider for web conferencing, and chat communications between the counselor and clients. The client is responsible for securing his or her own computer hardware, internet access points, and password security.
The counselor has a right to her privacy and may wish to restrict the use of any copies or recordings the client makes of their communications. Clients must seek the written permission of the counselor before recording any portion of the session and/or posting any portion of said session on internet websites such as Facebook or YouTube. Counselor cannot become friends with clients on social media; such as Facebook, Twitter, etc…
Potential benefits: The potential benefits of receiving mental health services online include both the circumstances in which the counselor considers online mental health services appropriate and the possible advantages of providing those services online. For example, the potential benefits of video sessions include the convenience for clients to potentially receive counseling from anywhere once an internet signal and necessary hardware is secured.
Potential risks: There are various risks related to electronic provision of counseling services related to the technology used, the distance between counselor and client, and issues related to timeliness. Confidentiality could be breached in transit by hackers or Internet service providers or at either end by others with access to the client’s account or computer. People accessing the internet from public locations such as a library, computer lab, or café should consider the visibility of their screen to people around them. Position yourself to avoid others’ ability to read your screen. Using cell phones can also be risky in that signals are scrambled but rarely encrypted.
Safeguards: The client is responsible for creating and using additional safeguards when the computer used to access services may be accessed by others, such as creating passwords to use the computer, keeping their email and chat IDs and passwords secret, and maintaining security of their wireless internet access points. Please discuss any additional concerns with your counselor early in your first session so as to develop strategies to limit risk.
Alternatives: Online counseling is a non-acute service and may not be appropriate for many types of clients including those who have numerous concerns over the risks of internet counseling, clients with active suicidal or homicidal thoughts, and clients who are experiencing active manic/psychotic symptoms. An alternative to receiving mental health services online would be receiving mental health services in person. HOH can and will assist clients who would like to explore face-to-face options in their area. Please feel free to request a referral at any time you think a different counseling relationship would be more practical or beneficial for you.
Proxies: HOH requires this consent form to be signed by the legal guardian of any client seeking services who is under the age of 18. The name and contact information of the legal guardian will be kept as part of the client’s record.
Confidentiality of the client: Maintaining client confidentiality is extremely important to the counselor and the counselor will take ordinary care and consideration to prevent unnecessary disclosure. Information about the client will only be released with his or her express and written permission with the exceptions of the following cases: 1) If the counselor believes that someone is seriously considering and likely to attempt suicide; 2) if the counselor believes that someone intends to assault another person; 3) if the counselor believes someone is engaging or intends to engage in behavior which will expose another person to a potentially life-threatening communicable disease; 4) if a counselor suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult; 5) if a counselor believes that someone’s mental condition leaves the person gravely disabled.
Records: HOH will maintain records of online counseling and/ or consultation 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 as required by applicable legal and ethical standards according to the American Counseling Association, National Board of Certified Counselors, the State of Tennessee Department of Mental Health and Substance Abuse Services. The client will be asked in advance for permission before any audio or video recording would occur on the counselor’s end.
Procedures: The counselor might not immediately receive an online communication or might experience a local backup affecting internet connectivity. 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: 1-800-SUICIDE or 1- 800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY).
Payments: It is up to the Client to keep HOH informed of any insurance/financial changes. HOH will bill any insurances that are accepting charges for telephone and/or video-based modalities. All client credit/debit card payments will be processed through Square. I understand payment of fees is expected at the time of service. Client agrees to pay for each service at the time it is rendered. Client understands they are responsible for all charges incurred, insurance will be filed as a courtesy to the client. Client will notify HOH at least 48 hours in advance if he/she is unable to keep appointment.
Disconnection of Services: If there is ever a disruption of services on the internet then the client will need to call your counselor to discuss how to proceed with the session. Your counselor can be reached at 615-597-4673.
APPOINTMENTS:
COUNSELING: Haven of Hope Counseling is based on an hourly system and functions on a tight schedule. Even when you are late, the appointment will still end on schedule. Individuals are expected to be available by phone during the session in case of an interruption in the teletherapy/video session service.
APPOINTMENTS NOT CANCELLED 48 HOURS PRIOR TO THE MEETING TIME ARE CHARGED. If HOH is able to reschedule someone for that time, or your counselor makes the cancellation, you will not be charged.
CHARGES:
Up to 55 minutes - $110(Every 10 minutes over, $25) Up to 45 minutes - $95
Up to 25 minutes - $60 Family Session - $100 Missed appointment - $35
PAYMENT IS DUE WHEN SERVICES ARE RENDERED. It is the responsibility of the client to maintain the account up-to-date to assure continuation of services.
