CUP OF TEA COUNSELING, LLC - CLIMATE GRIEF GROUP INFORMED CONSENT

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Email *

Legal first and last name *

DOB *

Address (number, street, city, state, zip code) *

Phone # *

Emergency contact information (full name, phone #) *

Local emergency information (hospital, police, or mental health crisis unit; phone #) *

Group Therapy Guidelines: Please confirm you understand and agree to the following terms by checking the boxes below. *

Maintain group confidentiality.

Be open to discussing climate issues through an intersectional, racial- and social-justice oriented lens.

Keep camera on during sessions (required so the therapist can monitor client well-being).

Commit to attending all group sessions.

Meet with group facilitator prior to the first session for a 15min screening.

Must be located in IL to participate.

Other guidelines the group creates.

Required

Client Rights and Responsibilities: Please confirm you understand and agree to the following terms by checking the boxes below. *

I agree to enter a virtual group counseling relationship with Colleen Aziz, LCPC, in the State of Illinois. I understand Colleen Aziz, LCPC has earned her Master of Arts degree in Human Development Counseling and is licensed as a Licensed Clinical Professional Counselor in the State of Illinois.

CONFIDENTIALITY: Information shared with my counselor is confidential except in the following circumstances: if my counselor believes I am a threat to myself or others; if my counselor suspects or confirms child or elder abuse; if mandated by a judge’s signed order; or if I sign a release of information.

While neither Colleen Aziz, LCPC nor Cup of Tea Counseling can guarantee other group participants will keep my identity confidential, I understand the expectation is that all participants will maintain confidentiality, and I commit to maintaining the confidentiality of all group members.

I must provide Cup of Tea Counseling, LLC with my emergency contact person and local emergency information in case of emergency. My emergency contact information will only be contacted for emergency and safety reasons.

I have the right to expect professional, ethical, and culturally competent behavior from my counselor as outlined in the ACA Code of Ethics (2014) and the Illinois Professional Counselor and Clinical Professional Counselor Licensing and Practice Act (225 ILCS 107/ and Part 1375; links below).

I have the right to access my group progress notes and/or terminate group counseling at any point, for any reason.

Group counseling can be both a joyful and painful process. I acknowledge I am responsible for my own growth and change process; I will get out what I put into group counseling, and I am accountable for my choices. My counselor, Colleen Aziz, LCPC and other group members will support, guide, challenge, and assist me within the group setting.

The group counseling process includes but is not limited to the practice of education, relationship processing, accountability, referral to resources, problem solving, skills training, help with decision making.

I understand my counselor will communicate with me via email to schedule sessions and share therapeutic resources, and that these communications will generally occur on weekdays only, Monday thru Friday.

Required

Notice of Privacy Practices: The following is a Notice of Privacy Practices. This is necessary legal information I, Colleen Aziz, LCPC, am required to share with clients. Please confirm you understand and agree to the following terms by checking the boxes below. *

I must be 18 or older to participate in virtual group counseling.

I must be located in the State of Illinois during all written and virtual communication with my counselor. I must not be operating a moving vehicle while engaging in virtual group counseling.

I am aware virtual group counseling is different in nature from face-to-face and/or individual assessment, diagnosis, and/or counseling sessions by a licensed, qualified mental health professional. I understand virtual group counseling is the practice of delivering clinical mental health care in a group setting via technology-assisted media and/or other electronic means between a practitioner and client(s) who are located in two different locations.

I acknowledge that if virtual group counseling services are interrupted by technology failure, my counselor and I will reestablish communication via a client-specific secondary method, such as a phone call to the number I've provided in this informed consent document.

I agree that while I can email my counselor to facilitate scheduling and the sharing of therapeutic resources, my counselor cannot respond to email in a clinical manner. All clinical work will occur within the scheduled virtual group counseling sessions.

I am aware that if I encounter my counselor in person, she will not approach or communicate with me to protect my confidentiality. I may approach or communicate with them if I so choose, understanding that action may indicate I am a client receiving group mental health counseling.

I acknowledge my counselor has a professional social media presence (LinkedIn, Instagram) and I can elect to follow her on social media for educational purposes only. I understand she will not follow me to protect my privacy.

Any electronic device I use to access my Protected Health Information (PHI) is password-protected and HIPAA-compliant to prevent unauthorized access, and my counselor Colleen Aziz, LCPC also uses password-protected and HIPAA-compliant electronic devices to prevent unauthorized access. I agree to engage in virtual group counseling and communicate about this service with my counselor only when using a private device on a secure network. I acknowledge the risks of a security breach of my information if I were to use a publicly-accessed device or shared network for my virtual group mental health care. I understand there will be no recording of any of the virtual group sessions by any parties.

The virtual venue does not allow for emergency response, therefore I understand the service provided through Cup of Tea Counseling, LLC is not intended for crisis situations and urgent mental health needs. I acknowledge, confirm and agree that the online platform used to communicate with my counselor and the group is not designed for use in any of the aforementioned cases and that I must not use the platform in any of the aforementioned cases.

My PHI is protected by state and federal law (HIPAA). This information can only be disclosed with my express permission or as required or permitted by law. All of our written communication is available on my personal electronic device to keep or share at my discretion. It is recommended that I keep this information/communication private and password protected if I copy or store it on my personal electronic device(s).

We are using virtual platforms and a technical support team that may have access to my information supervises this platform. This venue has taken all precautions to protect my privacy and confidential information. The platform depends on various factors such as software, hardware and virtual tools, either our own or those owned and/or operated by our contractors and suppliers. We do not guarantee that the platform will be uninterrupted or that it will be secure, consistent, timely or error-free. I understand there are risks, benefits, and consequences associated with virtual group mental health care, 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. Cup of Tea Counseling, LLC is not responsible for communication via cell phones, chat, email or video sessions. Precautions are used when utilizing these methods of communication. I will not hold Colleen Aziz, LCPC nor Cup of Tea Counseling, LLC liable for any gathering or use of client information by these service providers.

Required

Appointment and Payment Policies: Please confirm you understand and agree to the following terms by checking the boxes below. *

The group runs on "pay what you can." Contributions are not expected nor required to participate.

If you choose to contribute, you can send funds via Google Pay (colleen.aziz.lcpc@gmail.com) or Venmo (@cupofteacounselingil)

Required

Crisis Plan

Please acknowledge you agree to the Crisis Plan by marking the checkboxes below.

As the client, I understand the service provided through Cup of Tea Counseling, LLC is not intended for crisis situations and urgent mental health needs. In a crisis situation (ie, if I am a threat to myself or someone else), I agree to call 911 or local emergency services, call or text the National Suicide Prevention Lifeline at #988, or visit the nearest emergency room. Information shared with my counselor is confidential except in the following circumstances: if my counselor believes I am a threat to myself or others; if my counselor suspects child or elder abuse; if my counselor believes myself or another person is at risk of hurting themselves or someone else AND has access to firearms; if mandated by a judge’s signed order; or if I sign a release of information. *

Please confirm you understand and agree to the following statement by checking the box below.

I agree.

I do not agree, and will seek counseling services elsewhere.

Required

Client Signature *

Please confirm you understand and agree to the following statement by typing your legal name in the box below.

Date *

YYYY

Relevant Laws and Ethics

ACA Code of Ethics (2014)

Illinois Professional Counselor and Clinical Professional Counselor Licensing and Practice Act (225 ILCS 107/ and Part 1375)

Illinois Department of Financial and Professional Regulation License Lookup

Colleen Aziz, LCPC

colleen.aziz.lcpc@gmail.com

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