Welcome. To begin your counseling journey this form will provide you with information on the process of counseling, confidentiality, emergencies, and other details about your treatment.

Jewish Family Service offers counseling services both on-site and through video conferencing. If your counseling need is appropriate for tele-mental health, you can receive counseling via one medium, or a combination of both. Initial intake sessions are generally conducted on-site, unless there are extenuating circumstances that prevent an on-site visit. Be advised that it is your responsibility to check Telehealth coverage with your insurance provider (if billing through insurance Please not that some insurance providers do not cover family sessions.

All Tele-mental Health interactions are done through a Business Associates Agreement with Zoom Video Communications, and are HIPPA compliant. Before your first video session, you will be asked to create an account with Zoom Video Communications. You will be provided with step by-step instructions on how to set up your account and how to navigate your first experience using Zoom for Tele-mental health. Please note:

• We do not use email, texting, chat or telephone for sessions with clients. However, you can use secure messaging for brief interactions with your therapist through Zoom.
• It is recommended that you sign on to your Zoom account at least 5 minutes prior to your session start time.
• You are responsible for initiating the connection at the time of your session.
• If you do not initiate the meeting at your scheduled time or contact your clinician within ten minutes of your session start time it will be considered a “No-show” and you will be charged a $25 no-show/late cancellation fee for the session.
• Avoid using mind altering substances prior to session.
• Dress appropriately during web-based sessions as you would if you were attending a session at your clinician’s office.
• Be located in an area that is safe, provides privacy and is appropriate for a web-based session, such as a home office.
• Do not have anyone else in the room unless you first discuss it with your therapist.
• Do not conduct other activities while in session, such as driving.
• Do not bring weapons of any kind to the session.
• Do not record sessions without first obtaining the provider’s approval.
• Be located within the State of Nebraska, where our therapists are licensed to practice.
• Minors should have a parent or guardian with them at the location/building of the web-based session, unless otherwise agreed upon with their therapist.

You will have to have a brief interaction either on-site, or via video conferencing in order to verify your identity by matching you with your picture ID.

Always use a private and safe environment for your sessions. If someone enters your space during your session at your location simply acknowledge their presence by saying hello and your therapist will automatically disconnect from the session. This is to protect your privacy. Inform your therapist if you would like to establish a different protocol with them.

When you need to contact your therapist for any reason, please call our office at 402 330-2024. You may leave messages on our voicemail, which is confidential. In order to maintain professional boundaries with our clients, we do not accept connections via social media.

Tele-mental health should not be viewed as a substitute for on-site counseling or medication by a physician. It is an alternative form of counseling with possible benefits and limitations. By signing this document you agree that you understand that tele-mental health:

• May lack visual and/or audio cues, which may cause misunderstanding.
• May have disruptions in the service and quality of the technology used.
• May not be appropriate if you are having a crisis, acute psychosis, or suicidal or homicidal thoughts.

When you suspect that you may have misinterpreted your therapist’s statements, it is important to assume that he/she has positive regard for you, and to check out your assumptions. This will reduce any unnecessary hardship.

If you get disconnected from a video conferencing session, end and restart the session. If you are unable to reconnect within five minutes, call your therapist at 402-330-2024. If we do not hear from you within ten minutes, you agree (unless you request otherwise) that we can call you on the phone number you provided on the client information form.

• When using technology for communication, there is a risk that it may be forwarded, intercepted, circulated, stored, or even changed, and the security of the devices used may be compromised. Although we make reasonable efforts to protect the privacy and security of all electronic communication with you, it is not possible to completely secure the information.
• If you use any other methods of electronic communication with us, other than the means recommended by us, there is a reasonable chance that a third party may be able to intercept that communication. It is also important to be aware that family, friends, co workers, employers, and hackers may have access to any technology, devices, or applications that you use.
• We encourage you to only communicate through a computer, or any other device that you know is safe, and to follow the safety measures that are detailed on the “HIPAA Notice of Privacy Practices” document provided at intake. You are responsible for reviewing the privacy settings and agreement forms of any applications or technology you use. Please contact your therapist with any questions that you may have on privacy measures.

If you are ever experiencing an emergency, including a mental health crisis, please call 911, or go to your nearest emergency room. If you need to contact your therapist about an emergency during business hours, the best method is to call our main office phone, 402 330-2024. If you need assistance after hours, our emergency phone, 402 630-2707, is monitored by the therapist who is on-call. Due to the number of scam calls we receive daily, we advise you to please leave a voicemail, and your call will be returned shortly.

• So that we are able to get you help in case of an emergency and for your safety, the following are important and necessary. In addition, by signing this agreement form you are acknowledging that you understand and agree to the following:
• You, the client, will inform your therapist of the location in which you will be consistently during the sessions, and will inform your therapist if this location changes.
• You, the client, will identify on your client information form an emergency contact person whom we are allowed to contact in the case that we believe you are at risk.

By signing below you acknowledge that you have RECEIVED, READ AND UNDERSTOOD the above documents and agree to accept Tele-mental Health services through Jewish Family Service.

You may, at any time during the course of your treatment, withdraw your authorization to this agreement form as a whole. Jewish Family Service reserves the right to discontinue Tele-Mental Health sessions if we determine it is no longer conducive to a client’s treatment / progress.