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.