TeleHealth Services Informed Consent for Behavioral Health Services

This informed consent is to provide you with information about the Henderson Student Counseling Services (HSCS) telehealth services for the NSU Center for Student Counseling and Well Being and the Broward College Student Assistant Program. This consent serves as an addition to the HSCS Informed Consent Form and will be used only if telehealth services are being utilized. Per Florida Statute, (F.S. §456.47), telehealth refers to the use of telecommunication technology by a provider to provide health care services. This provision of services may consist of audioconferencing or videoconferencing through a personal laptop, computer with webcam, or smartphone. Telehealth services are offered to increase accessibility to counseling services to students, especially when significant barriers of travel to campus for counseling services are present. Please read carefully and sign document as confirmation of consent for telehealth services at HSCS.

Potential Risks and Benefits of telehealth:

HSCS partners with Let’s Talk Interactive® for access to the secure and private Zoom platform to execute telehealth services.
• Risks to confidentiality: Telehealth sessions take place outside of the confidential offices of HSCS, therefore, there is potential to be overheard or experience interruption of session if you are not located in a private space during the session. It is important that you protect your privacy and participate in sessions only if you are in a private space. HSCS counselors typically provide services from the on-campus office; however, during rare situations, counselors may operate remotely. They take reasonable efforts to operate in a secure and confidential space, minimizing interruptions and distractions.
• Risks to confidentiality: Telehealth sessions take place outside of the confidential offices of HSCS, therefore, there is potential to be overheard or experience interruption of session if you are not located in a private space during the session. It is important that you protect your privacy and participate in sessions only if you are in a private space. HSCS counselors typically provide services from the on-campus office; however, during rare situations, counselors may operate remotely. They take reasonable efforts to operate in a secure and confidential space, minimizing interruptions and distractions.
• Efficacy: While research shows that telehealth is about as effective as in-person face-to-face counseling, there is a risk of misunderstandings due to limited visual or auditory cues. For students with increased risk of harm to self or others or a clinical concern about level of psychiatric symptoms, in-person services may be recommended and deemed necessary.

Client Eligibility & Responsibilities:

Enrolled students who reside in Florida maybe eligible to participate in telehealth services. To engage in services, your physical location must be in Florida. The only exception is crisis consultations. If you are physically located outside of Florida, you must immediately notify the counselor. You will need a computer, laptop, or smartphone with a microphone, speakers, and a camera for audio and/or videoconferencing. You will need to use a reliable and secure internet connection rather than public or free wifi. You will need to have space that ensures your privacy (you are alone in the room and others cannot hear you), has enough lighting, and is free from distractions and/or interruptions. You should be appropriately dressed as if you were attending an in-person session. Do not attend sessions while under the influence of alcohol or drugs.
If the session is interrupted (i.e. call drops, video session gets disconnected) your counselor will attempt to re-connect with you via the telehealth platform you agreed to conduct session. If you do not receive a follow-up call in 5 minutes, you will then contact the HSCS office at:

NSU Center for Student Counseling and Well Being: (954) 424-6911
Broward College Student Assistance Program: (954) 424-6916
University of Miami On-call services available to students currently enrolled in services.

Address of the location that you plan to access Telehealth services from:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I give permission for telephone communication in the event of disruption to video. (Please Initial)*

I give permission for email communication. (Please Initial)*

Email Address*

example@example.com

I give permission to provide verbal consent for treatment plans and may request a copy via encrypted email or regular mail. (Please Initial)*

Appointments and Fees:
Sessions will be scheduled during mutually agreed upon time with your counselor, and you may not record the session. Session invitations will be sent via the email address you provide. HSCS attendance policy applies to all types of services, including telehealth. Please note that if you will not be able to attend an appointment, you are required to cancel or reschedule 24-hours in advance of the appointment to avoid the session counting towards your allotted sessions of your service year. Psychiatric service fees apply and we request that you cancel or reschedule your psychiatric appointment no less than 24-hours in advance to avoid being charged a $25 fee.

Confidentiality and Record Keeping:
Participation in telehealth treatment at HSCS requires provision of minimal identifying information to be shared with Let’s Talk Interactive® including your name, e-mail address, and telephone number. Let’s Talk Interactive® is a HIPAA-compliant platform that adheres to strict confidentiality laws. While the Notice of Privacy Practices have been covered and signed off on in the HSCS Counseling Agreement, if you have any questions about confidentiality, please ask your counselor.

Emergency/Crisis Situations:
HSCS offers a 24-hours a day, 7 days a week after hours crisis line, 365 days a year.
• If you are in imminent danger to yourself or others, call 911 or have someone take you to the closest emergency room immediately.
• If we are concerned about you, if we lose contact with you, or if you fail to show for a scheduled audio- or videoconference, we will contact you by phone to check on your wellbeing.
• If you are showing signs of being in crisis and/or are known to us to be in crisis and do not show for your scheduled audio- or videoconference, we require that you provide permission to contact a third party to ensure your safety. We require two levels of contacts to be identified in order to participate in online services:

A close personal contact such as a parent, spouse, sibling, or friend with whom you have regular on-going contact:*

First NameLast Name

Relationship*

Phone Number*

Please enter a valid phone number.

A professional contact such as a Student Affairs professional, a residence hall director, or a personal physician:*

First NameLast Name

Relationship*

Phone Number*

Please enter a valid phone number.

In addition, should HSCS find it necessary to contact the organization or entity that performs crisis wellness checks in your community (typically a 24-hour crisis service or the police department), we will do so.

In the case that you feel your symptoms are worsening and/or you are in distress, we request that you observe the following procedures below if you are in a crisis and need to speak to a counselor:
• During our business hours, please call the HSCS office to speak to the counselor on duty and/or make arrangements for an appointment.
• After hours, please call the HSCS main number to be connected to the on-call counselor:
NSU Center for Student Counseling and Well Being: (954) 424-6911
Broward College Student Assistance Program: (954) 424-6916
University of Miami On-call services available to students currently enrolled in services.

If I show signs of distress or deterioration that indicate that I may be in danger, by initialing the statements below, I agree to have them included in my safety plan:

I grant HSCS permission to contact me by phone and to leave a message. (Please Initial)*

I grant HSCS permission to contact:*

NSU: NSU Assistant Dean for Student Development and NSU CARE Team.BC: Associate Vice President, Student ServicesUM: Director of Student Services, University of Miami Miller School of Medicine

If I fail to respond to phone messages, I grant HSCS permission to contact those individuals listed above to verify my well-being. (Please Initial)*

If I exhibit behaviors indicating a risk for self-harm or harm to others, I understand and grant permission for HSCS to contact the organization or entity that performs wellness checks in my community to ensure my safety. This may also take the form of a wellness check conducted through my local police department. (Please Initial)*

I have been informed about the purpose, expectations, possible benefits and risks, and crisis procedures. I agree to participate and abide by the above stated expectations and client responsibilities in order to participate in telehealth services. I consent to participate in utilizing Let’s Talk Interactive® for telehealth services at Henderson Student Counseling Services.

Print Name*

First NameLast Name

Signature*

Date of Birth*

MonthDayYear

Today's Date*

Date