- JOB SHADOWING AGREEMENT

Name of Candidate:

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Your Initials:

Name of CBHC QMHS Employee:

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Employee You Are Shadowing's Initials:

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Please check all of the following basic mental health competencies that will be demonstrated during the job shadowing assignment:

An understanding of how to therapeutically engage a mentally ill person.Concepts of recovery/resiliency.An understanding of the community mental health system.De-escalation techniques.Understanding how their behavior can impact the behavior of individuals with mental illness.

I understand that job shadowing with a QMHS Worker from CBHC will require entering personal homes.

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During the course of shadowing, I may have access to personal health information (‘PHI”) relating to clients of CBHC including personal data, medical records, insurance and financial records, individually identifiable health information or other information that is conveyed to be confidential.

I agree that without CBHC’s prior written consent, I will not: (a) disclose PHI to any third party, whether electronically, orally, or in writing; (b) make or permit to be made copies or other reproductions of PHI; (c) make any use of PHI; or (d) use or disclose PHI in violation of applicable law, including but not limited to HIPAA

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Candidate Signature

Date