Telehealth Consent

I have been asked to participate in a TELEHEALTH SESSION that is under the direction of the STAR Council on Substance Abuse (STAR Council). The purpose of this telehealth session is to provide substance abuse related screening, treatment, and/or education services through a two-way interactive audio/video connection between the STAR Council Credentialed Counselor and myself. My treatment during this temporary period may include treatment plan reviews, assessments, as well as other therapeutic aspects of the treatment process as deemed necessary.

I understand the following:

1. I will receive substance abuse evaluation, treatment and/or education services by a Licensed Clinical Dependency Counselor (LCDC), Licensed Professional Counselor (LPC), or by an LCDC-Intern or LPC-Intern under the supervision of a Qualified Credentialed Counselor (QCC).
2. I may request that the session be discontinued at any time.
3. The evaluation and treatment, and the results of the evaluation and treatment, will be strictly confidential and only shared with individuals that I have given written consent to release information to.
4. There will be a documented confidential record of each session provided by the STAR Council Counselor and myself maintained in the CBMHS Documentation System.
5. These Telehealth sessions will be provided on a temporary based during the COVID-19 pandemic.
6. Every effort will be made to structure the sessions so there will be effective follow-up care, and I will have the opportunity to express any concerns I may have.
7. There are potential problems with the use of this new technology. These include but are not limited to: Interruption or disconnection of the audio/video link; an unclear picture or image; electronic tampering.
8. If any of the above problems occur, the visit might need to be stopped.
9. The telehealth process and evaluation has been explained to me.
10. I know the visit may not be equal to a face-to-face visit with a Counselor.
11. If I have any questions before, during, or after the visit, I may contact my Counselor by phone are the local office number or at our Toll Free number: 800-375-1395.
12. I know that I may be asked to give verbal consents during my telehealth visits and I understand that I may have to sign paperwork at a later date, i.e. treatment plan review.
13. I verify that I will be the only person present at my location during all telehealth sessions.

I certify this form has been fully explained to me. I have read it or had it read to me, and I understand its contents. I agree to participate in the telehealth session offered on this temporary bases and I consent to receive substance abuse evaluation, treatment, and/or education via telehealth.