The Rape Crisis Center of the Coastal Empire recognizes that the clients have the right to raise grievances about any matter relating to their receiving services from the Rape Crisis Center of the Coastal Empire, regardless if it involves a volunteer, staff member or other client. The welfare of our clients is paramount to the mission of the Rape Crisis Center of the Coastal Empire and this grievance policy and procedure is in place to ensure that all clients’ receiving services through the Rape Crisis Center of the Coastal Empire are treated with respect and are treated in a fair manner.

1. If a client has a complaint against a staff member, a volunteer or the Rape Crisis Center of the Coastal Empire agency as a whole, they should first discuss this with the HR Consultant from Focus One of Savannah Representative, who will act as an unbiased, third party to resolve the issue at the lowest level while documenting both the complaint and the outcome. In addition, the client may request an in-person meeting with the HR Consultant from Focus One of Savannah Representative to present supporting documentation for their grievance, if applicable, and in this case, if the nature of the grievance does require an in-person meeting, the HR Consultant from Focus One of Savannah Representative may ask that the Executive Director be present for the meeting.

2. If the Executive Director is the person who the grievance is against, then the matter should be taken directly to the Rape Crisis Center of the Coastal Empire’s Board of Directors and elevated to the President of the Board for consideration.

3. If the client has presented their grievance to the members of the Rape Crisis Center of the Coastal Empire and/or the appropriate Board members, and the issue is not resolved to their satisfaction, the Rape Crisis Center of the Coastal Empire will refer the client to the Criminal Justice Coordinating Council for further review.

My signature below indicates have read and received the Rape Crisis Center of the Coastal Empire’s Client Grievance Policy and Grievance form.

One of the goals of counseling is to identify and find effective ways of coping with problems that interfere with daily living or cause inner conflicts. During counseling you will be supported and given tools to help you achieve your individual goals both in and outside of counseling sessions. You will also be empowered to face challenges in your healing and growth process. Counseling is a partnership between both the client and counselor. It is expected that clients will take an active role in their counseling. This includes working on things talked about both during and in between sessions. Clients are encouraged to discuss any questions or concerns they may have about the counseling process with the counselor. It is important that clients are able to explore their concerns and work together with the counselor to resolve them.

All things disclosed in counseling sessions will be kept confidential with the exception of a few situations that may arise. Some of those exceptions are listed below.

Duty to Warn and Protect: When a client discloses an intent or plan to harm another person, the counselor is required to warn the intended victim and report this information to legal authorities. If a client discloses or implies a plan for suicide, the counselor is required to notify legal authorities in an attempt to get further help for the client.

Abuse of Children and Vulnerable Adults: If a client states or suggests that he or she is abusing or has recently abused a child or vulnerable adult (elderly, disabled) or if a child or vulnerable adult may be in danger of abuse, the counselor is required by law to report this information to social services and/or legal authorities.

Court Orders: In some cases (not typically) a judge may order the disclosure of a client’s private information; this order can be appealed. It is not guaranteed that the appeal will be sustained, but the counselor will do everything possible to keep counseling records confidential.

I understand that I will not involve or engage the counselor in any legal issues or litigation in which I am a party to at any time either during my counseling or after counseling terminates. This would include any interaction with the Court system, attorneys, Guardian ad Litems, psychological evaluators, or any other contact with the legal system. In the event that I wish to have a copy of my records, and I execute a proper release, RCC, will provide me a summary of my treatment. I understand that if I subpoena my counselor, she may elect not to speak with my attorney, and a subpoena may result in the counselor withdrawing as my counselor and referring me to another counselor.

As a client and visitor to the Rape Crisis Center of the Coastal Empire it is expected that you do not attend a counseling session under the influence of drugs or alcohol. The counselor reserves the right to reschedule any sessions in which a client may be under the influence of drugs or alcohol and unable to benefit from counseling at that time.

In order to ensure a safe environment for all clients, visitors, and staff the Rape Crisis Center of the

Coastal Empire prohibits the possession or use of perilous weapons on the property. This includes, but is not exclusive to guns and knives. A license to carry a weapon does not supersede this policy.

• If you need assistance after hours you can call the Rape Crisis 24 hour hotline 912-233-7273. Other 24 hr Crisis Line Numbers
• National Suicide Prevention Lifeline:1-800-273-8255
• Crisis Text Line: Text “HOME” to 741741 If you have a mental health emergency:
• Dial 911 or visit the nearest emergency room
• Contact Georgia Crisis Hotline at 1-800-715-4225 (1-800 -715-GCAL)

I have read the above information and understand that I have the right to agree to, or to refuse counseling services provided by Rape Crisis Center of the Coastal Empire. The counseling services will be provided at no charge to me. By signing below, I am indicating my desire to receive these counseling services.

Parent/Guardian’s Printed Name Parent/Gaurdian Signature Date

Thank you so much for choosing our counseling services. This document is designed to inform you about what you can expect regarding confidentiality, emergencies, and several other details regarding your treatment as it pertains to TeleMental Health. TeleMental Health is defined as follows: “TeleMental Health means the mode of delivering services via technology-assisted media, such as but not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system or other electronic means using appropriate encryption technology for electronic health information. TeleMental Health facilitates client self-management and support for clients and includes synchronous interactions and asynchronous store and forward transfers.” (Georgia Code 135-11-.01) TeleMental Health is a relatively new concept despite the fact that many therapists have been using technology-assisted media for years. Breaches of confidentiality over the past decade have made it evident that Personal Health Information (PHI) as it relates to technology needs an extra level of protection. Additionally, there are several other factors that need to be considered regarding the delivery of TeleMental Health services in order to provide you with the highest level of care. The Different Forms of Technology-Assisted Media Explained

It is important for you to know that even landline telephones may not be completely secure and confidential. There is a possibility that someone could overhear or even intercept your conversations with special technology. Individuals who have access to your telephone or your telephone bill may be able to determine who you have talked to, who initiated that call, and how long the conversation lasted. If you have a landline and you provided me with that phone number, I may contact you on this line from my own landline in my office or from my cell phone, typically only regarding setting up an appointment if needed. If this is not an acceptable way to contact you, please let me know.

In addition to landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone could overhear or intercept your conversations. Be aware that individuals who have access to your cell phone or your cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call occurred. However, we realize that most people have and utilize a cell phone. We may also use a cell phone to contact you.

Text messaging is not a secure means of communication and may compromise your confidentiality. Furthermore, sometimes people misinterpret the meaning of a text message and/or the emotion behind it. Therefore, we do not utilize texting as a part of the counseling services. If you happen to send a text message for the counselor by accident to our advocate number, you need to know that the counselor is required to keep a copy or summary of all texts as part of your clinical record that address anything related to therapy.

Emailing is not a secure means of communication and may compromise your confidentiality. Therefore, I do not utilize email with any of my clients, and I will not respond to an email message for your protection. If you happen to send me an email by accident, you need to know that I am required to keep a copy or summary of all emails as part of your clinical record that

address anything related to therapy.

It is our policy not to accept "friend" or "connection" requests from any current or former clients on our personal social networking sites such as Facebook, Twitter, Instagram, Pinterest, etc. because it may compromise your confidentiality and blur the boundaries of our relationship. However, RCC has a Facebook and Instagram page. You are welcome to "follow" RCC there. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to RCC. Please refrain from making contact with the counselor or any RCC staff using social media messaging systems such as Facebook Messenger or Twitter as these methods have insufficient security.

Video Conferencing is an option for us to conduct remote sessions over the internet where we not only can speak to one another, but we may also see each other on a screen. I utilize Doxy.me, This VC platform is encrypted to the federal standard, HIPAA compatible, and has signed a HIPAA Business Associate Agreement (BAA). The BAA means that Doxy.me is willing to attest to HIPAA compliance and assumes responsibility for keeping our VC interaction secure and confidential. If we choose to utilize this technology, I will give you detailed directions regarding how to log-in securely. I also ask that you please sign on to the platform at least five minutes prior to your session time to ensure we get started promptly. Additionally, you are responsible for initiating the connection with me at the time of your appointment. I strongly suggest that you only communicate through a computer or device that you know is safe (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc

During the course of our treatment, I may recommend that you visit certain websites for pertinent information or self-help. I may also recommend certain apps that could be of assistance to you and enhance your treatment. Please be aware that websites and apps may have tracking devices that allow automated software or other entities to know that you've visited these sites or applications. They may even utilize your information to attempt to sell you other products. Additionally, anyone who has access to the device you used to visit these sites/apps, may be able to see that you have been to these sites by viewing the history on your device. Therefore, it is your responsibility to decide if you would like this information as adjunct to your treatment or if you prefer that I do not make these recommendations. Please let me know by checking (or not checking) the appropriate box at the end of this document.

Your Responsibilities for Confidentiality & TeleMental Health

Please communicate only through devices that you know are secure as described above. It is also your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, strangers, and hackers could either overhear your communications or have access to the technology that you are interacting with. Additionally, you agree not to record any TeleMental Health sessions.

The counseling services we provide are outpatient services and we are able to accommodate individuals who are reasonably safe and resourceful. Our counselor does not carry a beeper nor is available at all times. If at any time this does not feel like sufficient support, please inform your counselor, who can discuss additional resources or transfer your case to a therapist or clinic with 24 hour availability. The counselor will return phone calls within one business day. The counselor does

not return calls on weekends or holidays. If you are having a mental health emergency and need immediate assistance, please follow the instructions below.

• If you have a mental health emergency, I encourage you not to wait for communication back from me, but do one or more of the following:
• Call Behavioral Health Link/GCAL: 800-715-4225
• Call National Suicide Prevention Lifeline at (800) 273-8255 (National Crisis Line)
• Call 911.
• Go to the emergency room of your choice.

Emergency Procedures Specific to TeleMental Health Services

• There are additional procedures that we need to have in place specific to TeleMental Health services. These are for your safety in case of an emergency and are as follows:
• You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and TeleMental Health services are not appropriate.
• I require an Emergency Contact Person (ECP) who I may contact on your behalf in a life-threatening emergency only. Please write this person's name and contact information below. Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or I determine necessary, the ECP agrees take you to a hospital. Your signature at the end of this document indicates that you understand I will only contact this individual in the extreme circumstances stated above. Please list your ECP here: Name: Phone:

• You agree to inform me of the address where you are at the beginning of every TeleMental Health session.
• You agree to inform me of the nearest mental health hospital to your primary location that you prefer to go to in the event of a mental health emergency (usually located where you will typically be during a TeleMental Health session Please list this hospital and contact number here: Hospital: Phone:

During a TeleMental Health session, we could encounter a technological failure. The most reliable backup plan is to contact one another via telephone. Please make sure you have a phone with you, and I have that phone number. If we get disconnected from a video conferencing or chat session, end and restart the session. If we are unable to reconnect within ten minutes, please call me. If we are on a phone session and we get disconnected, please call me back or contact me to schedule another session. Structure and Cost of Sessions

We offer primarily face-to-face counseling. However, based on your ability to make in-person sessions, the counselor may provide phone or video conferencing (at the discretion of the counselor) if your treatment needs determine that TeleMental Health services are appropriate for you. If appropriate, you may engage in either face-to-face sessions, TeleMental Health, or both. We will discuss what is best for you. The structure and cost of TeleMental Health sessions are exactly the same as face-to-face sessions described in the “General Informed Consent” form. There will be no cost for sessions.

You are responsible for the cost of any technology you may use at your own location. This includes your computer, cell phone, tablet, internet or phone charges, software, headset, etc.

In the event that you are unable to keep either a face-to-face appointment or a TeleMental Health appointment, you must notify your counselor at least 24 hours in advance.

Limitations of TeleMental Health Therapy Services

TeleMental Health services should not be viewed as a complete substitute for therapy conducted face-to-face, unless there are extreme circumstances that prevent you from attending therapy in person. It is an alternative form of therapy or adjunct therapy, and it involves limitations. Primarily, there is a risk of misunderstanding one another when communication lacks visual or auditory cues. For example, if video or audio quality is lacking for some reason, your counselor might not see a tear in your eye or hear the crack in your voice that could easily be picked up if you were in our office. There may also be a disruption to the service (e.g., phone gets cut off or video drops This can be frustrating and interrupt the normal flow of personal interaction. Please know that your counselor has the utmost respect and positive regard for you and your wellbeing. Your counselor would not do or say anything intentionally to hurt you in any way, and you are strongly encouraged to let the counselor know if something is done or said that upsets you. We invite you to keep communication open at all times to reduce any possible harm.

If we agree that TeleMental Health services are the primary way we choose to conduct sessions, there is a required face-to-face meeting at the onset of treatment. This initial meeting should take place in our office. If that is not possible, we can utilize video conferencing as described above. During this initial session, I will require you to show a valid picture ID. At this time, you will also

choose a password, phrase, or number which you will use to identify yourself in all future sessions. This procedure prevents another person from posing as you.

Consent to TeleMental Health Services

Please check the TeleMental Health services you are authorizing me to utilize for your treatment or administrative purposes. Together, we will ultimately determine which modes of communication are best for you. However, you may withdraw your authorization to use any of these services at any time during the course of your treatment just by notifying your counselor in writing.

Video Conferencing Telephone Counseling Recommendations to Websites or Apps

In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time. Feel free to ask questions, and please know that we are open to any feelings or thoughts you have about these and other modalities of communication and treatment.

Please print, date, and sign your name below indicating that you have read and understand the contents of this form, you agree to these policies, and you are authorizing our counselor to utilize the TeleMental Health methods discussed.

My signature below indicates that I have discussed this form with you and have answered any questions you have regarding this information.