Thank you for your interest in participating in virtual Expressive Arts Workshops with Solstice Healing Arts Collective. These workshops are facilitated by a member of Solstice Healing Arts Collective, who are all masters-level, clinically trained Art Therapists. However, these group sessions are NOT formal therapy sessions. Please read the following and complete this form prior to the start of the virtual expressive arts workshop:

I UNDERSTAND AND CONSENT TO THE FOLLOWING:
- Under Michigan Law “Telehealth” is defined as the use of electronic information and telecommunication technologies to support or promote long-distance clinical health care, patient and professional health-related education, public health, or health administration. Telehealth may include, but is not limited to, telemedicine. A “telehealth service” means a health care service that is provided through telehealth.

- The Art Therapist facilitator will make best reasonable effort to maintain privacy and confidentiality. I understand that my participation in the virtual group expressive art sessions are NOT formal therapy sessions. I understand that the same level of privacy, confidentiality, and therapeutic milieu cannot be assured with the group Expressive Arts Session on Zoom.

-I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; expressed threats of violence or harm to myself; and where I make my mental or emotional state an issue in a legal proceeding.

 - I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the therapist, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Solstice Healing Arts Collective DOES NOT utilize secure, encrypted audio/video transmission software to deliver Group Expressive Art Therapy Workshops on Zoom.

- I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.

- I understand that my personal information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than the art therapist facilitator in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the session.

- I understand that images of and from the session may be gathered by the facilitator and/Or Solstice Healing Arts Collective (please read and complete section on photographs and image collection below)

- By signing and completing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based therapetuic services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area. If i am unable to do so in case of an emergency, the group facilitator will contact my emergency contact listed here on my behalf