INFORMATION, AUTHORIZATION, & CONSENT TO BEING A COLLATERAL PARTICIPANT

Thank you very much for taking the time to read this authorization form carefully. We have given you this form because you have elected to become part of your friends’, family member's, spouse's, or partner's treatment. Although providing this document is part of an ethical obligation to our profession, more importantly, it is part of our commitment to you to keep you fully informed of every part of your experience here at The Resilience Group. Specifically, this document is to inform you about your rights, responsibilities, and risks regarding collateral participation. A "collateral participant," means that you are here to assist another person (the designated client), but you are not the primary focus of treatment. Please know that your relationship with the client's therapist is a collaborative one, and they welcome any questions, comments, or suggestions regarding your collateral participation.

DESCRIPTION OF COLLATERAL PARTICIPATION

The role of a collateral participant can vary greatly. For example, a parent or guardian may continuously be involved in the treatment of a minor. Whereas, a partner or friend may only come in once or twice to help the designated client. The client's therapist will discuss what role you shall take in the client's treatment during your first session. As mentioned above, the client's therapist is committed to providing treatment to the designated client, and your participation is adjunct to this treatment. Therefore, the therapist's legal and ethical responsibility resides strictly with the designated client. This means the following: (1) What the client tells their therapist is confidential, but what you tell their therapist is not. This isn't to say that the therapist plans to divulge any information that you tell them to the public. However, they will not keep secrets from the client, and your information isn't protected by the same laws that the information given to them by the client is. (2) Although your participation as a collateral may help you psychologically; it also may not. The therapist's primary concern is for the client, and treatment will focus on the client's needs. However, the therapist will be glad to give you other resources for your own treatment if necessary. (3) The therapist will keep a clinical record for the designated client only. Any notes they take regarding your participation will go into the client's chart. The client has the right to access their chart. Whereas, you do not have the right to access this chart without the client's written permission. Parents have a legal right to a minor's chart, but not an ethical right. (4) The therapist will give the client a diagnosis for treatment purposes and, if applicable, for insurance filing. However, the therapist will not give a collateral participant any kind of diagnosis.

PARENTS AS COLLATERAL PARTICIPANTS

Due to the sensitive nature of counseling and the fragile stage of development that your child is currently experiencing, forming a therapeutic bond with their therapist is very critical at this point. It is important that they feel safe and comfortable discussing personal and private topics with their therapist. In effort to respect the privacy and sensitive needs of your child, the therapist will not be discussing the content of therapy sessions with you in detail. It is our hope that through the therapeutic process new skills and insights will be gained by your child so they can discuss these sensitive topics with you in their own time. If your child is too young to do this, the therapist will definitely have family meetings to assist in this process. However, if at any time the therapist makes the assessment that your child is in danger or might be dangerous to others, if abuse/neglect is suspected or reported, or if there are any other concerns related to the health and welfare of your child, you will be notified immediately so that the necessary actions and precautions can be taken.

BACKGROUND INFORMATION AND THEORETICAL VIEWS

Information regarding the designated therapist's educational background and experience may be found on our website under their.

Please feel free to view that information at https://resiliencecounselingandconsulting.com.

It is our belief that as people become more aware and accepting of themselves, they are more capable of finding a sense of peace and contentment in their lives. However, self-awareness and self-acceptance are goals that may take a long time to achieve. Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of therapy. Furthermore, it is our policy to only see clients who we believe have the capacity to resolve their own problems with the therapist's assistance. It is the intention of the client's therapist to empower the designated client in their growth process to the degree that they are capable of facing life’s challenges in the future without the therapist. We also don’t believe in creating dependency or prolonging therapy if the therapeutic intervention does not seem to be helping. If this is the case, the client's therapist will direct the client to other resources that will be of assistance to them.

CONFIDENTIALITY & RECORDS

As mentioned above, your communications with the client's therapist will become part of a clinical record of treatment for the designated client, and it is referred to as the client's Protected Health Information (PHI), protected by both federal and state law. Your PHI will be stored electronically with TherapyNotes, a secure electronic health records company who has signed a HIPAA Business Associate Agreement (BAA). The BAA ensures that they will maintain the confidentiality of the PHI in a HIPAA compatible secure format using point-to-point, Federally approved encryption.

Additionally, the PHI of the client is confidential, with the following exceptions: (1) the client directs their therapist to tell someone else and signs a “Release of Information” form; (2) The client's therapist determines that the client or you are a danger to yourself or to others; (3) the client or you report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; (4) the sessions are being billed to an insurance company, and the client's insurance company requires the client's therapist to submit information about treatment for claims processing or utilization review; or (5) The client's therapist is ordered by a judge to disclose information. Regarding an order by a judge, the therapist's license does provide the therapist with the ability to uphold what is legally termed “privileged communication.” Privileged communication is the client's right to have a confidential relationship with a therapist. This state has a very good track record in respecting this legal right. If for some unusual reason a judge were to order the disclosure of the client's private information, this order can be appealed. We cannot guarantee that the appeal will be sustained, but we will do everything in our power to keep what the client says confidential. However, you should be aware that if a judge orders the disclosure of your information, the client's therapist does not have the legal authority to maintain your confidentiality. They only maintain that authority with the designated client. Additionally, it is expected that you will maintain the confidentiality of the client in your role as a collateral participant.

If at any point, the therapist determines that family or couples therapy is more appropriate than collateral participation, then you will be afforded all the rights to confidentiality that currently reside with the designated client. Please feel free to discuss this with the client's therapist if you have concerns.

STRUCTURE AND COST OF SESSIONS

Sessions are typically 50 minutes in duration. Occasionally, if the client's therapist feels more time is needed, they may be 75 minutes in duration, which the client's therapist will discuss with you prior to the appointment. Unless you elect to do so, or you are financially responsible for the client, you are not responsible for paying any of our professional fees.

CANCELLATION POLICY

In the event that you are unable to keep an appointment, you must notify the client's therapist at least 24 hours in advance. If such advance notice is not received, the client or you will be financially responsible for the session you missed unless the client decides to attend the session alone. Please note that insurance companies do not reimburse for missed sessions.

IN CASE OF AN EMERGENCY

Our practice is considered to be an outpatient facility, and we are set up to accommodate individuals who are reasonably safe and resourceful. We do not carry beepers nor are we available at all times. If at any time this does not feel like sufficient support for the person you are here to support, please feel free to inform the client's therapist, and you can discuss additional resources for the designated client or transfer the case to a therapist or clinic with 24-hour availability. However, if you are feeling that the client's therapist is not giving you enough support, this is a good indication that you might need to seek individual therapy for your own needs, which is discussed in the next section. Generally, we will return phone calls within 24-48 business hours. If you or the designated client has a mental health emergency, we encourage you not to wait for a call back, but to do one or more of the following:

• Call Behavioral Health Link/GCAL: 800-715-4225
• Call Coastal Behavioral Health at 912-354-3911
• Call 911.
• Go to your nearest emergency room.

PROFESSIONAL RELATIONSHIP

Psychotherapy is a professional service that we provide. Because of the nature of therapy, both your and the designated client's relationship with the therapist has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only a professional relationship. If you and/or the client were to interact with the therapist in any other ways, you would then have a "dual relationship." This could prove to be harmful to you or the client in the long run, and is unethical in the mental health profession. Dual relationships can set up conflicts between the therapist's interests and the collateral's or client’s interests, and then the collateral's or client’s interests might not be put first. In order to offer all of our clients and their collateral participant's the best care, the therapist's judgment needs to be unselfish and purely focused on client needs. This is why your relationship with the therapist must remain professional in nature.

Another example of a dual relationship is when a therapist attempts to treat close friends or multiple family members as separate individual clients. It's nearly impossible to focus on the needs of one individual without affecting the needs of others involved in a close relationship. Therefore, it is not advised in our profession, and the client's therapist cannot also become your individual therapist. If you determine that you would like your own therapist, we'll be glad to help you find another therapist to be of assistance.

One question you may have is if a collateral participant ever becomes a formal client of the therapist. The only time this might occur is if the client's therapist, the client, and you collectively decide that couples or family therapy is more appropriate and beneficial to all parties. However, if the client's therapist has had multiple sessions with the client and already developed a strong alliance, they will most likely refer couples or family therapy out to another professional. This will prevent a dual relationship as described above and allow for unbiased service to the couple or family.

You should also know that therapists are required to keep the identity of their clients and collaterals confidential. As much as the client's therapist would like to, for your confidentiality, the therapist will not address you in public unless you speak to the therapist first. The therapist also must decline any invitation to attend gatherings with your family or friends. Lastly, when the therapeutic relationship is completed, the therapist will not be able to be a friend to you like your other friends. In sum, it is the therapist's duty to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way, they are strictly for the client's and your long-term protection.

STATEMENT REGARDING ETHICS, CLIENT WELFARE & SAFETY

We assure you that our services will be rendered in a professional manner consistent with the ethical standards of the the American Counseling Association, National Association for Alcoholism and Drug Abuse Counselors, and World Professional Association of Transgender Health Providers. If at any time you feel that the client's therapist is not performing in an ethical or professional manner, we ask that you please let the therapist know immediately. If you are unable to resolve your concern, the therapist will provide you with information to contact the Owner/Clinical Director of The Resilience Group or the professional licensing board that governs their profession.

Due to the very nature of psychotherapy, as much as we would like to guarantee specific results regarding your participation or the therapeutic goals of the designated client, we are unable to do so. However, with your participation, the client's therapist will work to achieve the best possible results for the client as well as your relationship with him or her.

Additionally, as a support person for the client, it is important for you to know that at times people find that they feel somewhat worse when they first start therapy before they begin to feel better. This may occur as the client begins discussing certain sensitive areas of their life while in a session. However, once the client's therapist is able to target the specific treatment needs for the client and theparticular modalities that work the best, help is generally on the way.

TECHNOLOGY STATEMENT

In our ever-changing technological society, there are several ways we could potentially communicate and/or follow each other electronically. It is of utmost importance to us that we maintain the client's confidentiality, respect both of your boundaries, and ascertain that your relationship with the client's therapist remains professional. Therefore, we’ve developed the following policies:

Cell phones: It is important for you to know that cell phones may not be completely secure or confidential. However, we realize that most people have and utilize a cell phone. The client's therapist may also use a cell phone to contact you. If this is a problem, please feel free to discuss this with the client's therapist.

Text Messaging and Email: Both text messaging and emailing are not secure means of communication and may compromise confidentiality. We realize that many people prefer to text and/or email because it is a quick way to convey information. However, please know that it is our policy to utilize these means of communication strictly for appointment confirmations (nothing that could be inferred as therapy). Please do not bring up any therapeutic content via text or email to prevent compromising confidentiality. If you do, please know that the client's therapist will not respond. You also need to know that we are required to keep a summary or a copy of all emails and texts as part of the client's clinical record that address anything related to therapy.

Facebook, LinkedIn, Instagram, Pinterest, Twitter, Etc: It is our policy not to accept requests from any current or former clients on social networking sites such as Facebook, LinkedIn, Instagram, Pinterest, etc. because it may compromise confidentiality. The Resilience Group has a business Facebook page and Instagram account. You are welcome to follow us on any of these pages. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to The Resilience Group. Please refrain from making contact with us using social media messaging systems such as Facebook Messenger or Instagram Direct Message. These methods have insufficient security, and we do not watch them closely. We would not want to miss an important message from you.

Google, Bing, etc.: It is our policy not to search for our clients on Google or any other search engine. We respect your privacy and make it a policy to allow you to share information about yourself to the client's therapist as you feel appropriate. If there is content on the Internet that you would like to share with the client's therapist for therapeutic reasons, please print this material and bring it to your session.

Faxing Medical Records: If you authorize us (in writing) via a "Release of Information" form to send your medical records or any form of protected health information to another entity for any reason, we may need to fax that information to the authorized entity. It is our responsibility to let you know that fax machines may not be a secure form of transmitting information. Additionally, information that has been faxed may also remain in the hard drive of our fax machine. However, our fax machine is kept behind two locks in our office. And, when our fax machine needs to be replaced, we will destroy the hard drive in a manner that makes future access to information on that device inaccessible.

Recommendations to Websites or Applications (Apps): During the course of treatment, the client's therapist may recommend that you visit certain websites for pertinent information or self-help. They may also recommend certain apps that could be of assistance to you and enhance your treatment. Please be aware that websites and apps may have tracking devices that allow automated software or other entities to know that you've visited these sites or applications. They may even utilize your information to attempt to sell you other products. Additionally, anyone who has access to the device you used to visit these sites and/or apps, may be able to see that you have been to these sites by viewing the history on your device. Therefore, it is your responsibility to decide and communicate to the client's therapist if you would like this information as adjunct to treatment or if you prefer that the client's therapist does not make these recommendations.

In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time. Please feel free to ask questions, and know that we are open to any feelings or thoughts you have about these and other modalities of communication.

OUR AGREEMENT TO ENTER INTO A COLLATERAL RELATIONSHIP

We sincerely hope this document has been helpful to explain your role in the client's treatment, your rights, risks, and our procedures. If you have any questions about any part of this document, please ask. My physical or electronic signature on this form indicates that I have read all above information, it has been adequately explained to me, and I understand its contents. I am voluntarily agreeing to enter into a collateral relationship with The Resilience Group and understand my role in the client’s treatment. I understand that my PHI may be maintained on paper or in electronic format.