Online Informed Consent:
1. I understand that I have the following rights with respect to teleservices/virtual support:
- There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.
- Confidentiality still applies for teleservices, and nobody will record the session without the permission from the others person(s).
- We agree to use the video-conferencing platform selected for our virtual sessions, and the services provider will explain how to use it.
- You need to use a laptop, descktop, tablet or smartphone during the session.
- It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
- It is important to use a secure internet connection rather than public/free Wi-Fi.
- It is important to be on time. If you need to cancel or change your tele-appointment, you must notify your DSP in advance by phone or email.
- We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
- We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. (please provide it below)!
- You have to have the Virtual Support Services approved by your Team (SC, Guardian and Service Provider) and stated into your PCP before start receiving this type of service.
- If you have any voice device such as EchoDot or Alexa, it must be removed from the room! The HIPAA regulations don't allow any Voice devices to be present during the virtual service!
- As your Direct Support Provider, I may determine that due to certain circumstances, teleservices are no longer appropriate and that we should resume our sessions in-person.
2. The laws that protect the confidentiality of my personal and medical information also apply to teleservices. As such, I understand that the information disclosed by me during the session is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.