This Informed Consent for Technology-Assisted Counseling form is provided to inform counseling participants about the scope, limitations and benefits of Abuse Counseling and Treatment's BAN Program remote counseling services. Before acknowledging this form, all participants seeking to schedule a counseling session remotely must contact the ACT BAN Program to schedule their session. Prior to their remote counseling session, this Informed Consent for Technologically-Assisted Counseling form must be read and acknowledged by the participant. The participant acknowledges they read and understood the content presented in the form by providing their electronic signature on the line provided.

A. Privacy and Confidentiality
Counseling records are protected by Federal and State confidentiality regulations and cannot be disclosed without a participant's written consent. The exceptions to these regulations include incidents that could be deemed potentially life threatening, such as incidents of child abuse, suspected abuse of vulnerable adult, threats of suicide or homicide, or as required by law, i.e. by order of the court. Exceptions also include medical personnel in a medical emergency, and communication to law enforcement officers when the information is directly related to a client’s commission of a crime or threat to commit a crime on the premises of a domestic violence shelter.

1. Participant Confidentiality Precautions
Participants should consider all factors for preserving confidentiality prior to their remote appointment. Participants should evaluate if anyone has access to the device they will use for their appointment (i.e. family, co-workers, friends, significant others, etc.) A safe environment where they can attend their remote appointment should be assessed and utilized. It is not recommended, but participants who must access the internet from public locations such as a library, computer lab, or café should consider the visibility of their screen and/or audible volume of their speaking voice in relation to people around them. If using a computer, all online counseling session materials should be fully exited after the appointment has concluded. If using a mobile device, participants should be mindful of the use of location-services. All counselors and personnel at Abuse Counseling and Treatment and BAN Program follow strict guidelines to preserve and maintain the confidential rights of all participants. It is the participant's responsibility to evaluate their surroundings and modes for communication in order to further maintain their right to confidentiality upon attending their remote appointment. Participants are asked not to make any audio or video recordings of any portion of the session(s).

B. Participant's Rights, Risks, and Responsibilities:

Participants have the right to withhold or withdraw consent at any time without affecting their right to future care or treatment.

The laws that protect the counseling confidentiality and my personal information also apply to Technologically-Assisted Counseling. As such, I understand that the information disclosed by me during the Video Sessions and Group is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are described in this consent form for services.

Participants understand that there are risks and consequences of participating in Technologically-Assisted Counseling, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of counselors that: the transmission of participant information could be disrupted or distorted by technical failures; the transmission of participant information could be interrupted by unauthorized persons; and/or the electronic storage of participant information could be accessed by unauthorized persons.

There is a risk that services could be disrupted or distorted by unforeseen technical problems. As a result, participants understand that telephone/online based services and care may not be as complete as face-to-face services.

Participants understand that they may benefit from Technologically-Assisted Counseling, but that results cannot be guaranteed or assured. Participants understand that there are potential risks and benefits associated with any form of online counseling.

C. Appointment Equipment
The client is responsible for securing any of the following that applies, before their remote appointment with a counselor. Depending on the type of remote appointment, equipment could include: computer access, internet access, telephone access, telephone service.

D. The Absence of Non-Verbal Cues and Potential Miscommunications
Because remote modes of communication, including telephone and online video calls, are used for technologically-assisted counseling sessions, there are limitations to communication. Misunderstandings are possible when speaking over the phone or over video call due to the absence of non-verbal communication. Our facilitators, assessors and BAN staff will make every effort to fully understand, but may ask for clarification. We ask for your patience and understanding as we adapt and evolve to provide counseling services remotely.