CSC SoCal Information Form + Support Group Consent

CSC SoCal Information Form

...so that no one faces cancer alone.
All programs and services are offered at no charge to cancer patients and their loved ones. This is made possible by the generous donations of our participants, other individuals, and grants. We are not affiliated with any insurance company and we do not receive Federal or State funding. Please complete all parts of this form. The information helps us know who we serve, track needs, and understand how people are referred to us. As a nonprofit organization, information about who we serve (in statistical form only, never about an individual) is critical to ensuring continued funding. No identifying information is shared outside of CSC. Thank you!
Today's Date:

MonthDayYear
Preferred Title:

Mr.Mrs.MissMs.Other
Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Street Address:*
City:*
State:*
Zip Code:*
Are you currently residing in California?*

YesNo
Email:*
Phone (Home):*
Phone (Mobile):*
I identify as:*

ManWomanTransgender ManTransgender WomanNon-binaryPrefer not to answer
Marital Status:

SingleMarriedPartneredSeparatedDivorcedWidowed
Sexual Orientation*

StraightLesbianGayBisexualOtherPrefer not to answer
I am a:*

Cancer Patient or SurvivorCaregiver/Loved oneExperienced the recent death of a cancer patient
Cancer Patient's Treating Hospital or System of Care (indicate N/A as needed):*
Hospital or System of Care (indicate N/A as needed):*
How did you learn about Cancer Support Community (please be specific)?*
If yes, what age(s)?
Type of Cancer:
Date of Diagnosis:

MonthDayYear
Doctor/Oncologist:
Loved One's Name:
Loved One's Cancer:
Date of Passing:
Cancer Patient's Name:
Cancer Patient's Diagnosis:
Do you have any children under the age of 18?

YesNo
Several of our funding and accrediting agencies require us to ask for the following demographic information. The following information will be used for statistical purposes only and is not linked to your name.
Ethnic Background:*

White (not Hispanic)Latino/HispanicAmerican IndianAsian/Pacific IslanderAfrican American/Black (Non-Hispanic)African American/Black (Hispanic)Other
Number in Household:*
Annual Family Income:*

Under $25,000$25,000-$49,999$50,000-$74,999$75,000-$99,000Over $100,000
Insurance Status:*

MedicareMedi-Cal/MedicaidPrivate InsuranceUninsured
Employment Status:*

Full Time:Part TimeOn Medical LeaveDisabledNot EmployedRetired
Emergency Contact:*
Relationship:*
Emergency Contact Phone:*

Area CodePhone Number
Policies

Confidentiality

Our staff and volunteers respect the privacy of our participants. Cancer Support Community Southern California (CSC) adheres to professional, legal, and ethical standards of confidentiality established by professional organizations and state law. Legal and ethical exceptions to confidentiality include: a clear or present danger to harm oneself or another, knowledge of the abuse or neglect of a minor child, elder or dependent/incapacitated adult, or responses to a court subpoena or as otherwise required by law.

CSC asks that our participants respect each other’s privacy and do not disclose the identity of others who participate at CSC, or what is personally shared in a CSC program. However, we are not able to ensure confidentiality of all participants, as we would have no way to enforce it.

Consent Statement

By signing this document, I:
- Understand that CSC and program partners recommend that anyone participating in any exercise program check with their healthcare provider prior to participation to ensure that they are medically able to do so. Participation in any exercise program could result in injury or illness.
- Release, waive, discharge and hold harmless CSC and its program partners, affiliates, employees, officers, agents, independent contractors, volunteers and donors from any and all claims, actions, demands, liabilities, expenses (including attorneys’ fees) and losses arising from bodily injury or illness, including, but not limited to, wrongful death, loss of services, loss of consortium, and all other damages that may arise out of participation in an exercise or healthy lifestyle program.
- Authorize the use of the videoconferencing platform, Zoom, for the provision of and participation in distance-oriented programs.
Signature*

Clear
I wish to join a support group:*

YesNo
Please read the following information regarding support group policies and sign below to indicate that you understand and consent to the information:

CONFIDENTIALITY STATEMENT

There is great respect for confidentiality at Cancer Support Community Southern California (CSC). Very little that goes on in the group becomes public knowledge, not because of a promise or guarantee made by CSC, but because of the innate integrity of participants and the awareness of the harm that gossip can do, along with an implied, unspoken, but well-accepted agreement among the participants to hold confidential that which is spoken about in group. CSC staff respects the confidentiality of all participants. CSC reserves the right to breach confidentiality when a group member is thought to be a danger to self or others, when there is suspicion of child abuse, dependent adult abuse, or elder abuse, or when in compliance with the Court of Law.

CSC POLICY AGREEMENT
1. The Cancer Support Community Southern California (CSC) cannot and does not assure confidentiality.
2. CSC reserves the right to refuse or discontinue the use of its facilities or services to any person.
3. CSC does not provide medical advice or medical assistance of any kind.
4. Opinions expressed by participants in the group do not necessarily represent the philosophy of CSC.
5. I will try to attend at least three (3) meetings before deciding if a group is not for me.
6. I will inform my group Facilitator if I do not wish to be on the group roster.
7. Regular attendance in support groups is important. When I am unable to attend a group meeting, I will contact CSC beforehand for the purpose of informing the group.
8. I will share my thoughts and feelings and seek support in the context of the group as opposed to individual conversations with the Facilitator outside the group.
9. Many participants of CSC have impaired immune systems. If I develop a cold, the flu, or other communicable diseases I will not attend in-person group meetings until I am well.
10. I will be mindful before sharing or showing anything that could be considered graphic, offensive, or triggering to other group members.
11. When I have completed treatment and I am no longer dealing with the day-to-day issues of cancer, I will consider graduating from my group to make room for someone else. Generally, this happens about 18 months post-treatment, but is always negotiable with the Facilitator.
In consideration of my acceptance as a Participant at CSC, and the use of the facilities and services provided without charge, I agree that I will not take any legal action against CSC, its officers, agents, employees, any other participants at CSC or CSC Headquarters, based in any way on what is said or done by such officers, agents, employees and participants at CSC in a good faith effort to provide those services and facilities.
SUPPORT GROUP TELEHEALTH CONSENT

This portion of the document indicates your consent to participate in distance-oriented support group sessions, otherwise known as telehealth, which take place over a HIPAA compliant telehealth platform, Zoom.

Further, this document is designed to inform you about what you can expect regarding confidentiality, emergencies, and several other details during group participation as it pertains to telemental health at the Cancer Support Community. Telemental health is the mode of delivering group counseling services via technology-assisted media, such as telephone (landline and mobile devices), video conferencing, internet, tablet, PC desktop system or other electronic means using appropriate encryption technology for electronic health information.

Limitations of Telemental Health:

We acknowledge that for some people getting to a physical Cancer Support Community facility is not possible. Telehealth can be utilized in circumstances that prevent you from in-person group support. Please be aware that there is a risk of misunderstanding group members when communication lacks visual or auditory cues. There may also be a disruption to the service (e.g., phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of group interaction.

In Case of Technology Failure:

During a telemental health support group, there could be a loss of phone or internet connection. If you get disconnected from a video conferencing group, end and restart the session. If you are unable to reconnect within ten minutes, please email the facilitator for instructions.

In Case of an Emergency:

If you have a mental health emergency, you are encouraged not to wait for communication back from your facilitator, but to do one or more of the following:
- Call Lifeline at (800) 273-8255 (National Crisis Line)
- Call 911
- Go to the nearest emergency room
You understand that if you are having suicidal or homicidal thoughts, experiencing symptoms of psychosis, or in a crisis that we cannot solve remotely, your facilitator may determine that you need a higher level of care and Telehealth services are not appropriate. Cancer Support Community requires an Emergency Contact Person who your facilitator may contact on your behalf in a life-threatening emergency only.

By Signing This Consent, You Understand and Agree to the Following:
- I will find a quiet and protected space for all group sessions.
- During group, no one else will be present in the room.
- I will not accept other phone calls, texts, emails or engage in web surfing during our sessions.
- If there is a loss of connection, I will refer to the In Case of Technology Failure item above.
- I know how to utilize video conferencing technology and/or agreed upon technology-assisted devices.
- I understand the limitations of telemental health and it is not a complete substitute to the programs offered at the Cancer Support Community.
- I understand that a telehealth support group has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
- I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
- I understand that my Cancer Support Community group facilitator can discontinue the group if it is felt that the videoconferencing connections are not adequate.
- I have had a direct conversation with Cancer Support Community staff during which I had the opportunity to ask questions regarding the potential risks and benefits of telemental health.
- My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
By signing this consent, I hereby indicate my compliance with the above stated expectations. I reserve the right to revoke my consent, in writing, at any time. I may specify the date, event or condition on which this consent expires. Please sign your name below indicating that you have read and understand the contents of this form, you agree to these policies, and you are authorizing your facilitator to utilize the Telemental Health methods discussed.
Signature*

Clear
NOTICE TO PARTICIPANTS

The Program and Clinical Director of Cancer Support Community receives and responds to complaints regarding the practice of psychotherapy by any unlicensed or unregistered practitioner providing services at Cancer Support Community. To file a complaint, contact Anna Swift, LCSW at a.swift@cancersupportsgv.org.

The Board of Behavioral Sciences receives and responds to complaints regarding services provided by individuals licensed and registered by the board. If you have a complaint and are unsure if your practitioner is licensed or registered, please contact the Board of Behavioral Sciences at 916-574-7830 for assistance or utilize the board’s online license verification feature by visiting www.bbs.ca.gov.
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