INFORMATION, AUTHORIZATION, AND CONSENT TO ONLINE SUPPORT

Gynecological Cancer Support Group

This document indicates your consent to participate in distance-oriented support group sessions, which takes place over the Zoom platform.

Further, this document is designed to inform you about what you can expect regarding confidentiality, emergencies, and several other details during group participation as it pertains to these online groups at BACC.

We acknowledge that for some people getting to the physical Bay Area Cancer Connections (BACC) location is not possible. Online services can be utilized in circumstances that prevent you from in-person group support. Please be aware that there is a risk of misunderstanding group members when communication lacks visual or auditory cues. 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 group interaction.

• I will provide my first name either as my Zoom name or verbally at the beginning of group.
• If I am new to the group, I agree to start the group with my camera on. If I do not feel comfortable being on camera for the entirety of the group, I will check with the facilitator first to discuss camera requirements for their group.
• If technological capabilities do not allow, I understand that it is okay to remain off-camera.
• I will find a quiet and protected space for all group sessions.
• During group, no one else will be present in the room.
• I will not accept other phone calls, texts, emails, or engage in web surfing during our sessions.
• If there is a loss of connection, I will refer to the In Case of Technology Failure item below.
• I know how to utilize video conferencing technology and/or agreed upon technology-assisted devices.
• I understand the limitations of support through online platforms and it is not a complete substitute to the programs offered at BACC.
• I understand that an online support group has potential benefits including easier access to support and the convenience of meeting from a location of my choosing.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
• I understand that BACC cannot guarantee confidentiality.
• I understand that the BACC facilitator can discontinue the group if it is felt that the videoconferencing connections are not adequate.
• I understand that it is my responsibility to ask the group facilitator or a member of the BACC staff if I have additional questions regarding the potential risks and benefits of utilizing this online platform.

During an online support group, there could be a loss of phone or internet connection. If you get disconnected from a video conferencing group, end and restart the session. If you are unable to reconnect within ten minutes, please email the facilitator for instructions.

If you have a mental health emergency, you are encouraged not to wait for communication back from your facilitator, but to do one or more of the following:

• Call Lifeline at (800) 273 - 8255 (National Crisis Line)
• Call 911
• Go to the nearest emergency room

You understand that if you are having suicidal or homicidal thoughts, experiencing symptoms of psychosis, or in a crisis that we cannot solve remotely, your facilitator may determine that you need a higher level of care.

By signing this consent, I hereby indicate my compliance with the above stated expectations. Please sign (or type) your name below and select the date, indicating that you have read and understand the contents of this form and you agree to these policies.

If you are submitting this Information, Authorization, and Consent to Online Support form after office hours and have not recieved the meeting information or can not access the meeting, please contact the facilitator. 

Lacey Morris, M.A. / 415-235-7802