I,   First Name*   Last Name*   hereby consent to myself or my child,   First Name   Last Name, participating in services with Family Connections through teleservice. I understand that teleservice may include case management, counseling, psychotherapy, psychoeducation, or supportive visitation, as offered by the Family Connections. Teleservice involves receiving services remotely via video conferencing or phone calls.
In addition to the in-person service risks and benefits referenced in Family Connections’ Treatment Authorization form, I understand that there are additional risks and benefits associated with teleservices. Benefits include the ability to connect with Family Connections and receive services without being in the same physical location. Teleservice risks include limited ability to respond to cases of emergency, potential technology interruptions (e.g., poor internet service, dropped calls, etc.), and potential privacy and security risks resulting from services being received via remote location (e.g., an unintended 3rd party intercepting electronic communication, conversation being overheard by someone sitting nearby, etc.).
 
By consenting to receive teleservices:
• I agree to participate in Family Connections services through the technology that provides the most security to protect my privacy and is mutually available to Family Connections staff and me.
• I understand that Family Connections staff will review how I will be informed of upcoming appointments, procedures for communicating between appointments, technology interruption plans, and emergency procedures. I further agree to provide Family Connections staff with my location at the start of each appointment in the event of an emergency.
• I understand that Family Connections will take all steps reasonably necessary to minimize privacy and security risks related to teleservice on their side, including enabling all security features available on the agreed-upon communication platform and ensuring that our conversation cannot be seen or overheard by others at their location.
• I understand that I am encouraged to take privacy and security precautions similar to those outlined above and, if I am unable to do so, we may reschedule a service if proceeding with the service could be detrimental to my care.
• I understand that the privacy laws that protect the confidentiality of my Protected Health Information (PHI) also apply to teleservice, unless an exception applies as outlined in Family Connections’ Notice of Privacy Practices https://www.familyconnectionsnj.org/notice-of-privacy-practices/ or authorized due to the OVID-19 Public Health Emergency.
• I acknowledge that Family Connections’ staff can only control technology security settings on their side of the communication, can only manage privacy in their environment, and is not responsible if my Protected Health Information is seen overheard by others at my location, or if I have not maximized the security features of our agreed-upon communications.
• If participation includes group services: I also understand that participation in group services pose additional privacy and security risks as other group participants may not have taken the full steps necessary to help ensure confidentiality.  Family Connections’ staff will review group privacy and security requirements with all participants at the start of each group session and remove members who cannot adhere to these requirements if this information becomes known; however, staff may not know of all potential risks at each group member’s location.

I understand that my consent to participate in teleservice is voluntary and that I have the right to withdraw my consent at any time.  I further understand that teleservices are currently permissible due to the COVID-19 Pubic Health Emergency and that services may resume in-person as government-authorized or required by the entity paying for my service (e.g., Medicaid, insurance, DCPP, etc.).