TeleHealth Informed Consent Form

Agreement

I, the above, hereby consent to engaging in telehealth with a counselor at the JWCC office of counseling services (OCS). I understand that "telehealth" includes the practice of education, goal setting, accountability, referral to resources, problem solving, skills training, and help with decision making. Telehealth psychotherapy will occur primarily through interactive audio, video, telephone, email, instant messaging, and/or other data communications.

I understand that I have the following rights with respect to telehealth:

(1) I have the right to withhold or withdraw consent at any time. If consent is withheld or withdrawn, JWCC students may meet with the counselor onsite at any of the JWCC campus sites or may request a referral to a local mental health provider.

(2) Receiving telehealth services may be contraindicated with:
• Recent suicide attempt(s), psychiatric hospitalization, or psychotic processing (last 3 years)
• Moderate to severe major depression or bipolar disorder symptoms
• Moderate to severe alcohol or drug abuse
• Severe eating disorders
• Repeated “acute” crises (e.g., occurring once a month or more frequently)

(3) Nobody will record the session without permission from the others person(s)

(4) The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; expressed threat to harm or kill self; and where I make my mental or emotional state an issue

(5) I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures; the transmission of my personal information could be interrupted by unauthorized persons; and/or the electronic storage of my personal information could be accessed by unauthorized persons. In addition, I understand that telehealth based services and care may not be as complete as face-to-face services. I also understand that if my counselor believes I would be better served by another form of intervention (e.g. face-to-face services) I will be referred to a mental health professional who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of counseling, and that despite my efforts and the efforts of my counselor, my condition may not improve, and in some cases may even get worse.

(6) We agree to use the video-conferencing platform selected (ZOOM) for our virtual sessions, and the counselor will explain how to use it. It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. It is important to use a secure internet connection rather than public/free Wi-Fi.

(7) I understand that I have a right to access my personal information and copies of case records in accordance with Federal and Illinois law. I have read and understand the information provided above. I have discussed it with my counselor, and all of my questions have been answered to my satisfaction.

(8) By electronically signing this document I agree that certain situations including emergencies and crises are inappropriate for audio/video/computer based psychological counseling services.
• We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
• If I am in crisis or in an emergency I should immediately call 9-1-1 or seek help from a hospital or crisis oriented health care facility in my immediate area. I understand that emergency situations include if I have thought about hurting or killing either another person or myself, if I have hallucinations, if I am in a life threatening or emergency situation of any kind, having uncontrollable emotional reactions, or if I am dysfunctional due to abusing alcohol or drugs.
• I acknowledge I have been told that if I feel suicidal, I am to call 9-1-1 or the National Suicide Hotline Toll-Free Number at 1-800-784-2433 or other local suicide hotlines.