I have been asked to participate in a TELEHEALTH SESSION that is under the direction of the CW OUTREACH BIPP Program. The purpose of this telehealth session is to provide BIPP Services through a two-way interactive audio/video connection between the CW OUTREACH BIPP Director/Facilitator and myself. My services during this temporary period may include Intake Assessments, Orientation, Groups, as well as other program aspects as deemed as necessary.

I understand the following:

1.  I will receive BIPP services by a CW OUTREACH BIPP Director/Facilitator.

2.  I may request that the session be discontinued at any time. 

3.  The information gathered during Intake Assessment and Orientation will be strictly confidential and only shared with individuals that I have given written consent to release information to.

4. There will be a documented confidential record of each session provided by the CW OUTREACH BIPP Director/Facilitator and myself reflected on the program roster.

5.These Telehealth sessions will be provided on a temporary based during the COVID-19 pandemic until otherwise directed by the

6. Every effort will be made to structure the sessions so there will be effective follow-up care, and I will have the opportunity to express any concerns I may have.

7.  There are potential problems with the use of this new technology. These include but are not limited to: Interruption or disconnection of the audio/video link, an unclear picture or image, and/or electronic tampering.

8.  If any of the above problems occur, the visit might need to be stopped.

9.  The telehealth process and evaluation has been explained to me.

10. I know the visit may not be equal to a face-to-face visit with a session.

11. If I have any questions before, during, or after the visit, I may contact my BIPP Director/Facilitator by phone at 254-979-5380.

12. I understand that I will have to sign my consents virtually via a link that is provided.

13. I verify that I will be the only person present at my location during all telehealth sessions as to maintain strict confidentiality.

14. I will be provided a random 6 digit code at the Intake Assessment session that will be my varication code while receiving Telehealth services. I understand that I am to provide this code at the beginning of every session to verify my presence.

I certify this form has been fully explained to me. I have read it or had it read to me, and I understand its contents. I agree to participate in the telehealth session offered on this temporary basis and I consent to receive BIPP services via Telehealth.