Reinstatement - Transfer In

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS
I,Name* hereby authorize Jackson Bibby Awareness Group to disclose information and records pertaining to my participation in the program to the following:
- The Department of Motor Vehicles.
- The Department of Alcohol and Drug Programs.
- The County Offices of Alcohol and Drug Abuse Services.
- The appropriate branches of the Judicial System.
- My personal attorney.
- My personal physician.
The disclosure of information and/or records herein authorized is required for the purpose of establishing or determining my status, progress, and/or compliance with the terms and conditions of my participation in the program. Such disclosure shall be limited to information and/or records in regard to my progress and participation in the program.

I understand that this authorization can be revoked by the undersigned at any time except to the extent that action has been taken in reliance thereon. If not earlier revoked, it shall terminate ninety (90) days after my participation in the program has ended. I also understand that despite the codes (California Civil Codes 56.11 and 56.15, and Federal Regulation CFR Section 2.31), confidential information and/or records may be disclosed without my authorization pursuant to state and federal law in the following circumstances:
- Pursuant to a proper subpoena or court order.
- Reporting child abuse or elder abuse.
- Reporting an individual who is a danger to him/herself or a third party.
- Reporting the intent to commit a crime on program premises or against program staff.
A photocopy, facsimile or duplicate copy of this authorization shall be as valid as the original.
Signature*

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Date*

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I,blanks* also hereby authorize Jackson Bibby Awareness Group to disclose information to my designated representative:
Name*
Relationship*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Such information shall be limited to information relating to payment, scheduling and in the case of emergencies, for the purpose of facilitating treatment. This authorization is guided by the same California Codes and Federal Regulations
stated above will terminate at the same time.
Signature Of Participate*

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Signature Of Witness

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TeleHealth Client Agreement
Dear Client,

As you are aware, the Novel Coronavirus (COVID-19) has impacted the daily lives of all Californians. All schools and some businesses are closed with more being affected every day. The latest direction from the Department of Health Care Services (DHCS) allows for the provision of temporary Remote Client Services also known as Telehealth.

To avoid a delay in completing your DUI Program, Jackson-Bibby Awareness Group, Inc. will begin offering th Remote Client Services on April 6, 2020.

Remote Client Services will enable you to continue your DUI classes with a certified counselor via a the Zoom virtual meeting platform temporarily during the COVID-19 crisis. To participate in Remote Client Services, you must:
- Sign the Client Letter and return it to Jackson-Bibby Awareness Group Inc. to the email based on your location:
  - Redlands: redlands.admin@jacksonbibby.com
  - Victorville: victorville.admin@jacksonbibby.com
  - Barstow: barstow.admin@jacksonbibby.com
- Register in advance for the session via an email link that will be sent to you in advance of the scheduled session.
- To receive credit for the session, you must:
  - Register with your full name as provided to us at Enrollment. Credit will not be given if any aliases or other screen names are input into Zoom.
  - Make sure you have paid for your virtual session in advance. Payment of credit card or debit card is only accepted at this time and payments can be made over the phone in advance.
  - Be In the virtual meeting at the provided start time. It is recommended that arrive at least 5 minutes early so that you can make sure the program is downloaded and all speakers and microphones are working.
  - Attend the session in a private room, free of distractions.
  - Stay for the entire session and participate when called upon.
  - Not be under the influence of alcohol or other drugs during the session. This is up to the counselor’s and administrators discretion.
Certain technology is required to participate in this program. You must have either a computer, tablet, or phone with a working microphone, speakers, and a camera (for video meetings You must also be able to download the free Zoom software onto a computer or download the Zoom application on a tablet or phone.

To take advantage of this unique opportunity and keep your DUI treatment program on track, read the privacy policy on the next page and sign where indicated. Return the signed page via email the email option listed above. If you have any questions, please email or contact your program location’s manager.

I have read and agree to Jackson-Bibby Awareness Group, Inc’s Telehealth Policy.
Name - Printed*
Current Email Address*
example@example.com
Signature*

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Privacy Policy for Remote Client Services
Jackson-Bibby Awareness Group, Inc. will provide Remote Client Services (Telehealth) utilizing the Zoom Virtual Meeting Platform. Some personal information such as your name, email address, and computer IP address will be shared with Zoom. Additionally, some meetings may be recorded and uploaded to a cloud for documentation of session completion. To participate in Zoom meetings, you must read and agree to Zoom’s Privacy Policy.

Jackson-Bibby Awareness Group, Inc will continue to maintain confidentiality as stated in our Confidentiality Policy. Client’s will also be held to the Confidentiality Agreement signed upon enrollment.
- To participate in temporary Remote Client Services, sign the release below and email the signed page to the following:.
- Redlands: redlands.admin@jacksonbibby.com
- Victorville: victorville.admin@jacksonbibby.com
- Barstow: barstow.admin@jacksonbibby.com
Remote Client Services Release
I (print your name)blanks* agree to participate in temporary Remote Client Services (Telehealth) at Jackson-Bibby Awareness Group, Inc. I understand that specific technology is required to participate, and I certify that I have access to the required technology. Additionally, I have read and understood the Zoom privacy policy. I understand that Remote Client Services are being offered on a temporary basis due to the Coronavirus (COVID-19) pandemic and that once the threat is eliminated, client services will then be
available at the DUI Program location only. To receive credit for the session, I understand that I must adhere to the policies outlined in the Telehealth Client Agreement.

I understand that fees for DUI Program services will apply during this time and that Jackson-Bibby Awareness Group, Inc. will provide me with alternate payment options and methods during the Remote Client Services time period.

I have read and agree with Jackson-Bibby Awareness Group, Inc and Zoom’s Privacy Policy.
Name*
Date*

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Name - Signature*

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Client Email/Texting Informed Consent Form
1) Risk of using email/texting
1. The transmission of client information by email and/or texting has a number of risks that clients should consider prior to the use of email and/or texting. These include, but are not limited to, the following risks:
2. Email and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.
3. Email and text senders can easily misaddress an email or text and send the information to an undesired recipient.
4. Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy.
5. Employers and on-line services have a right to inspect emails sent through their company systems.
6. Emails and texts can be intercepted, altered, forwarded or used without authorization ordetection.
7. Email and texts can be used as evidence in court.
8. Emails and texts may not be secure and therefore it is possible that the confidentiality of such communications may be breached by a third party.
2) Conditions for the use of email and texts

The provider cannot guarantee but will use reasonable means to maintain security and confidentiality of email and text information sent and received. The provider is not liable for improper disclosure of confidential information that is not caused by provider intentional misconduct. Clients must acknowledge and consent to the following conditions:
1. Email and texting is not appropriate for urgent or emergency situations. Provider cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time.
2. Email and texts should be concise. The client should call and/or schedule an appointment to discuss complex and/or sensitive situations.
3. All email can be printed and filed into the client’s record. Texts may be printed and filed as well.
4. Provider will not forward client’s identifiable emails and/or texts without the client’s written consent, except as authorized by law.
5. Clients should not use email or texts for communication of sensitive medical information.
6. Provider is not liable for breaches of confidentiality caused by the client or any third party.
7. It is the client’s responsibility to follow up and/or schedule an appointment if warranted.
Client Acknowledgement and Agreement
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of email and/or texts between Jackson-Bibby Awareness Group, Inc (provider) and me, and consent to the conditions and instructions outlined, as well as any other instructions that the provider may impose to communicate with me by email or text.
Client name*
Client signature*

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Email Address*
example@example.com
Location*
Should be Empty:

PERSONAL DATA INTAKE INFORMATION FORM

In Case Of Emergency Contact:

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

TeleHealth Client Agreement

Privacy Policy for Remote Client Services

Remote Client Services Release

Client Email/Texting Informed Consent Form

Client Acknowledgement and Agreement