Teletherapy Consent Form

On behalf of myself or as a legal guardian of a minor child, I authorize and voluntarily consent to participate in teletherapy provided by a counselor from The Sexual Assault/Spouse Abuse Resource Center (SARC). By choosing this option, I understand that:

1. Teletherapy is the use of interactive audio, video or other telecommunications or electronic media that allows face-to-face communication between a therapist and client.
2. Clinical risks may include discomfort with virtual face to face vs in-person treatment, difficulties interpreting non-verbal communication, and importantly, limited access to immediate resources if risk of self-harm or harm to others becomes apparent.
3. Teletherapy does not provide emergency services. If I am experiencing an emergency situation, I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the Suicide Hotline 1-800-SUICIDE for free 24-hour hotline support.
4. I am responsible for providing the necessary secure computer, telecommunications equipment and internet access for my teletherapy session. I will make arrangements to secure a location with privacy that is free from distractions, intrusions or interruptions during my teletherapy session.
5. Any internet-based communication is not 100% guaranteed to be secure/confidential. The teletherapy system used by SARC Doxy.me meets HIPAA standards for encryption and privacy protection. You will not have to purchase a plan or provide your name when you “join” an online session. Your counselor will provide you with a link to connect to your session. You can just enter your name as “client”. SARC has made every reasonable effort to implement technical security measures that reduce risks of a confidentiality breach. I understand the risk and I agree that SARC and my therapist should not be held responsible if any outside party gains access to our therapy session.
6. The teletherapy session occurs in the state of Maryland and is governed by the laws of Maryland.
7. I understand that technical problems may occur. If a call is disrupted, the therapist will call back unless technical difficulties persist. In such cases, the session can be rescheduled via phone.
8. Due to the pandemic public health crisis of the Coronavirus, Covid-19, it has become possible for treatment delivery to occur via interactive video-conferencing (i.e. virtual “face to face” sessions) in lieu of, “in-person” sessions. Treatment delivery via doxy.me will only be used during this time and in-person sessions will resume when it is safe to do so. In the event teletherapy is not in my best interest, my therapist will explain that to me and suggest alternative options better suited to my needs.
9. My consent to teletherapy can be withdrawn by providing written notification to my therapist. My signature below indicates that I have read this consent form and agree to its terms.
10. If I need support between scheduled therapy sessions, I understand that SARC's 24-hour helpline is available to me at 410-836-8430.
11. Anything you share will remain confidential, unless you disclose abuse or neglect of a child, elder or vulnerable adult, or the intent to harm yourself or others.

For any minor participating in counseling, if there is a custody order in place a copy of the decree must be provided so that the parent's right to consent to treatment can be verified.

I hereby grant permission to SARC staff to share information about my case with other members of the Maryland Network Against Domestic Violence Lethality Assessment Project Team. The members of the Project are currently as follows: Aberdeen Police Department, Havre De Grace Police Department, Harford County Sheriff’s Office’s Domestic Violence Unit, SARC’s Program Directors and the Executive Director. The Harford County State’s Attorney’s Office will also participate in case reviews as needed, and will therefore receive case information. It is anticipated that additional law enforcement agencies will join the Lethality Project in the future to provide assistance to victims.

 It has been explained, and I fully understand that the case review process is part of the project to test and improve the usability and effectiveness of the Lethality Screen for First Responders and Danger Assessment.

 I understand that the case review process is a coordinated effort for the purpose of monitoring my situation and degree of safety. The information shared will be part of the Project’s objective to have a coordinated team approach for victims in potentially lethal situations. Law Enforcement Agencies and the State’s Attorney’s Office are not bound by agreements of Confidentiality and therefore any information disseminated to these agencies cannot be guaranteed to remain restricted.

 I understand that I may revoke this release at any time.

If a client is dissatisfied with the services he/she is receiving at SARC, the client should first inform the employee providing the services and attempt to reach a resolution. If the issue is not resolved to the client’s satisfaction, the client may request to meet with the employee’s supervisor. The client may contact the supervisory staff by calling 410-836-8431 and asking for the Clinical supervisor, the Legal supervisor, or the Safehouse supervisor. Supervisors may request a written statement regarding the client’s complaint at any time. If the client remains dissatisfied with the resolution taken by the supervisor, he/she may appeal in writing to the Executive Director. The Executive Director will respond in writing to the client within ten (10) business days or receipt. If the Executive Director is unavailable at the time the complaint is submitted, the written complaint will be acknowledge by the appropriate designee and the client will be informed that the Executive Director will respond upon return to the office.

If a client is still dissatisfied, he/she may appeal in writing to the Personnel Committee of
SARC’s Board of Directors. The letter should include an explanation of the issue and steps taken. The Personnel Committee will review the information and may recommend procedural changes at SARC to address the issues presented.

For discrimination complaints, clients may request a copy of the Discrimination Complaint Form from any staff member. SARC is required to forward a copy of all discrimination complaints to the Maryland Commission on Human Relations and notify the Governor’s Office of Crime Control and Prevention of the complaint. During the entire grievance process, all necessary care will be taken to ensure that confidentiality and privileged information remains intact.

This policy is specific to services rendered by SARC employees, not non-agency outcomes including housing or court rulings. In addition SARC’s internal process, the Attorney Grievance Commission oversees the conduct of both Maryland lawyers and nonmembers of the Maryland Bar who engage in the practice of law in the State. The Commission investigates and, where indicated, prosecutes attorneys whose conduct violates the Maryland Lawyers Rules of Professional Conduct as well as those engaged in the unauthorized practice of law.

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I have read the above, or it has been read to me and explained. I understand the SARC grievance procedure.

· You have the right to privacy and uncensored communications except in situations             where there is a threat to self or other, or where child abuse/neglect is involved.

· You have the right to be treated with dignity and respect.

· You have the right to self-determination. You have the right to make your own choices.

· You have the right not to be shamed or blamed for having been a victim.

· You have the right to be free from all forms of abuse: physical, mental, emotional,               psychological or sexual.

· You have the right to live in a safe and humane environment.

· You have the right to worship in the religious faith of your choice.

· You have the right to be informed of all program services.

· You have the right to individualized services unless there is good cause to deny or               terminate these services.

· You have the right to give your input into your goals and plans that are made.

· You have the right to seek legal counsel.

· You have the right to not be discriminated against in the provision of services to                 you due to gender, age, disability, income, race, religion, ethnic origin, English                   proficiency, immigration status, or sexual orientation.

It is the policy of SARC to protect the identity of its clients. Whenever staff and volunteers discuss cases, the names, details of the case, and any descriptive circumstances of the client shall not be revealed to any other person outside the agency except when necessary to comply with superceding law, rule of professional conduct, or court order. Names and/or details of any case may be discussed only in the agency on a need-to-know basis as part of the professional care-giving process and to provide all appropriate services. 

In the course of counseling, many concerns and subjects are discussed. All dialogue between staff, clients, and volunteers, is confidential WITH the following exceptions. All staff and volunteers must report suspected child abuse to the Department of Social Services or the police. Any potentially harmful acts that are committed by the client, either to him/herself or to others shall be reported to the target of harm or proper authorities in order to prevent potential homicide or suicide. These incidents must be discussed with the Executive Director to inform the agency.

I understand that maintaining a clients’ confidentiality is paramount to a client’s safety.

I am required to keep clients’ confidences.

I will not publicly acknowledge another client without his/her expressed permission.

I have read the above, or it has been read to me and explained. I understand that a knowing and voluntary violation of the confidentiality policy will result in the potential for suspension or termination of services.

I understand domestic violence is a potentially lethal situation and in the event of my death, as a result of domestic homicide or suicide, I hereby waive my right to confidentiality. I understand information about my interactions with SARC may be discussed with other agencies as part of a learning process.

I wish to be contacted in the following manner (please check all that apply):

•  If you can’t make an appointment, please be sure to contact SARC at least 24 hours prior to your appointment. Due to high demand and the limited availability of counseling appointments, if you miss two appointments in a row, your appointment time will no longer be able to be held for you and will be offered to another client waiting to receive services.

• If you do not have any scheduled appointments for a thirty day period, your counselor will make a reasonable attempt to contact you for three weeks. If your counselor is unable to reach you by phone after three weeks, the counselor will send a letter to a safe address that you have provided above. If you do not respond by the date given in the letter, your case will be closed. If you contact us after this time
  and there is a waitlist, you will be seen based upon availability of therapists.

• Please let your counselor know if there are any changes in the address or the telephone number(s) above.

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I agree that I have read the above cancellation policy and that the above methods of communication can be used. This form will be valid for the duration of participation in Clinical Services at SARC but I can amend it at any time.