I hereby consent to participate in telehealth services with the Family Resource Centre (FRC) of the Department of Counselling Services.
I understand that telehealth services is the practice of delivering parenting services via technology assisted media or other electronic means between a FRC staff member and a client who are located in two different locations.
With respect to telehealth services:
1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
2) I understand that there are risks, benefits, and consequences associated with telehealth services, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
4) I understand that everything said during the telehealth call is confidential.
5) I understand that there are exceptions to your right to confidentiality. You will be
informed of any time when we will have to put these into effect.
If there is good reason to believe that:
a.
You will harm another person, we must attempt
to inform that person and warn them of your intentions. We must also contact
the police and ask them to protect your intended victim.
b. You are abusing or neglecting a child (anyone
under the age of 18) or vulnerable adult, or if you give information about
someone else who is doing this, we must inform the Department of Children and
Family Services promptly, sometimes immediately depending upon the risk to the
individual
d. You are in imminent danger of harming yourself
then it is our professional responsibility to keep you safe; the police and hospital
will be called. All other options will be explored with you prior to taking any
action.
e. You inform us that another named health or
mental health care provider has engaged
in sexual contact with a client, including yourself, a report will be filed.
f.
You
are involved or become involved with the court system or probation; information
regarding your attendance and progress at the Department is provided.
g. Your file
is subpoenaed by the court system, the Department must comply.
6) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis, that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care or intervention is required.
7) I understand that the FRC assigned worker may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
8) I understand that during a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs and we are unable to reconnect within ten minutes, please contact the assigned worker or the Family Resource Centre at 949-0006
