• I understand that me and my child/children are electing to take part in teleconferencing sessions with my provider (counselor, case manager, advocate, or other Impact NW, Parent Child Therapist Program worker) via video and/or messenger.

 

• My provider has explained that teleconferencing will not be the same as a direct client/provider visits due to the fact that I/we will not be in the same room as the provider and these services are not to be used as emergency or urgent medical services. 

 

• I understand that telehealth (virtual visits, teleconferencing) has potential benefits including easier access to care and convenience. 

 

• I understand telehealth services take place in a private, stationary location with a verifiable address.

 

• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my provider or I can discontinue use of teleconferencing if there is reason to believe this service is not adequate for the situation.

 

• I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

 CONSENT TO TAKE PART IN TELECONFERENCING

By electronically signing or providing a handwritten signature to this document, I acknowledge:

• Teleconferencing is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911, Multnomah County Crisis (503) 988-4888, or go directly to my closest emergency room.

 

• If there is any problems or loss of contact or connection during teleconferencing, I will contact my provider by phone through the number I have been provided in advance of our teleconference appointment.

 

• Though my counselor and I may be in direct, virtual contact through the Teleconferencing Service, the Teleconferencing service provider itself does not provide any medical, healthcare, or advice including, but not limited to, emergency or urgent medical services.

 

• To maintain confidentiality, I will not share my teleconferencing appointment link with anyone unauthorized to attend the appointment.

 

• I understand that I do not have to sign this consent form. It is my choice for me and my minor child/children to take part in teleconferencing for counseling and consultation sessions with my PCTS Counselor. I can refuse these services at any time without prejudice.

 

• I understand that any services provided via teleconferencing, forms or records uploaded or shared over teleconferencing will become a part of my healthcare record.

 

• I understand that my provider (counselor, case manager, advocate or other worker) does not make any video or audio recordings of our sessions without my expressed permission. I also agree not to make any audio or video recording of our sessions through teleconferencing without first seeking written permission from my provider.

 CONSENT AND SIGNATURES

With my electronic signature to this form, I certify: That I have read or had this form read and/or had this form explained to me. That I fully understand its contents including the risks and benefits of the procedure(s). That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

 updated: 4/29/2021 S.R.