Telehealth Consent

STAR Council has 3 office locations, which of the following is closest to you? *

all sessions are currently provided via ZOOM

STAR Council has 3 office locations, which of the following is closest to you? *

all sessions are currently provided via ZOOM

First and Last Name:*

Last name first.

Date of Birth:*

Date

Services provided by electronic means, under the direction of STAR Council on Substance Abuse (STAR Council), utilize a HIPAA compliant virtual platform. The purpose of telehealth sessions is to provide substance use related screening, treatment, and/or education services through a two-way interactive audio/video connection between the Credentialed Counselor and myself. This consent covers all aspects of the treatment/therapeutic process as deemed necessary.

I understand and consent to the following:

The HIPAA compliant virtual platform used has the option of closed captioning for the hearing impaired.
Clients will need access to Wi-Fi or a cellular network to join sessions.
I will receive substance use screening, treatment and/or education services by a Licensed Chemical Dependency Counselor (LCDC), Licensed Professional Counselor (LPC), or by an LCDC Counselor Intern or LPC Associate under the supervision of a Qualified Credentialed Counselor (QCC).
All treatment will be strictly confidential and only shared with individuals that I have given written consent to release information to.
I understand that documents generated during telehealth services will be digitally signed and submitted via a HIPAA compliant platform to ensure the protection of client records. These documents will be maintained as part of the client’s confidential record for each session, to be maintained in the CBMHS documentation system.
There are potential problems with the use of technological services. These include but are not limited to: Interruption or disconnection of the audio/video link; an unclear picture or image; or electronic tampering. If any of the above problems occur, the visit might need to be stopped and rescheduled.
As a client receiving telehealth services, I understand that the following rules are part of the treatment program requirements:

I understand that I will make every effort to ensure all telehealth sessions are attended in a private location.
Joining each session in a private location to maintain privacy is required. Clients are to take special care that others at the home or location cannot listen in on sessions. If there are others that could possibly overhear session content, client is to find an alternative private location or wear headphones and turn on a fan or sound machine for background noise.
Disconnect/disable devices that could record or collect information from the environment i.e., google home assistant, Amazon Alexa, or Apple Siri.
No screenshots or recording of sessions is permitted. Violators will be dismissed from the Treatment Program without question.
Clients are to remain fully visible during the entire session, with exception to breaks.
No moving about or driving during the session. Violators will be removed from the session or group without credit.

If I have any questions before, during, or after the session, I may contact the Counselor by phone at (254) 965-5515 or Toll-Free at 800-375-1395.

I First and last name*, certify that I have read this consent, or had it read to me, and I understand its contents. I agree to receive substance use services via electronic means.

Todays Date: *

Date

Signature*