Informed Consent for TeleMental Health Services Confidentiality & Privacy Concerns/Recommendations Until further further notice, Imagine Behavioral Health will be utilizing Video Conferencing (VC) to provide TeleMental Health Services. These services will be conducted through the Zoom app. This VC platform is encrypted to the federal standard, HIPAA compatible, and has signed a HIPAA Business Associate Agreement (BAA). The BAA means that Zoom is willing to attest to HIPAA compliance and assumes responsibility for keeping our VC interaction secure and confidential. We will provide you with further detailed directions regarding how to log-in securely, and also ask that you please make every attempt to sign on to the platform at least five minutes prior to your session time to ensure we get started promptly. Additionally, we strongly suggest that you only communicate through a computer or device that you know is safe (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.), and that you find a location that will provide you with minimal possibilities for interruptions and/or confidentiality breaches. Our clinicians will be taking every possible step to insure your privacy and confidentiality by conducting sessions in a secure and isolated location, as well as utilizing headphones throughout the duration of your session. Even taking all necessary measures to ensure that your sessions are kept private and confidential, TeleMental Health Services still possess risks for potential breaches to confidentiality. Due to the possibilities of disconnection, staff may be forced to contact you via telephone and/or email. To reduce the possibility of compromises in your confidentiality, we recommend that you do not include any clinical information in emails and/or text messages, and that you place proper safeguards on cell phones to prevent unauthorized access to sensitive information. In Case of Technology Failure During a TeleMental Health session, we could encounter a technological failure. The most reliable backup plan is to contact one another via telephone. Please make sure you have a phone with you, and we have your phone number in our system. If we get disconnected from a video conferencing, the clinician will send an invitation to rejoin the video conference. If we are unable to reconnect within ten minutes, our clinician will reach out to you via telephone from a blocked number. If we are on a phone session and we get disconnected, please contact our offices and you will be rescheduled for another session. In Case of an Emergency Outside of Telehealth Services If you have a mental health emergency between your scheduled appointments, do not to wait for communication back from your clinician, but instead, utilize one or more of the following courses of action: ● National Domestic Violence Hotline: 1- 800-799-7233 ● National Suicide Prevention Lifeline: 1-800-273-TALK (8255); www.suicidepreventionlifeline.org ● Suicide Prevention, Awareness, and Support: www.suicide.org ● Lifeline Crisis Chat: https://www.contact-usa.org/chat.html ● Crisis Text Line: Text REASON to 741741 (free, confidential and 24/7) ● Self-Harm Hotline: 1-800-DONT CUT (1-800-366-8288) ● Family Violence Helpline: 1-800-996-6228 ● Call 911 ● Go to the nearest emergency room. Emergency Procedures Specific to TeleMental Health Services There are additional procedures that we need to have in place specific to TeleMental Health services. These are for your safety in case of an emergency and are as follows: ● You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and TeleMental Health services are not appropriate. ● I require an Emergency Contact Person (ECP) who I may contact on your behalf in a life-threatening emergency only. Please write this person's name and contact information below. Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or I determine necessary, the ECP agrees to take you to a hospital. Your signature at the end of this document indicates that you understand I will only contact this individual in the extreme circumstances stated above. Please list your ECP here: Emergency Contact Name* Emergency Contact Phone* ● You agree to inform me of the address where you are at the beginning of every TeleMental Health session. ● You agree to inform me of the nearest hospital to your primary location that you prefer to go to in the event of a mental health emergency (usually located where you will typically be during a TeleMental Health session). Please list this hospital and contact number here: Hospital Name* Hospital Phone* Consent Agreement & Signature By signing this document, I: (1) unconditionally release and discharge Imagine Behavioral Health, its affiliates, agents, employees, and my clinicians and his or her designees from any liability in connection with my participation in the remote consultation/s, (2) acknowledge that I have read this document carefully and fully understand the benefits and risks, (3) acknowledge that I have had the opportunity to ask any questions I have and have received satisfactory answers, (4) voluntarily consent to participate in the telebehavioral consultation(s), including but not limited to any care, treatment, and services deemed necessary and advisable, under the terms described herein. Patient Name* Date* MM slash DD slash YYYY Is the above release for a minor or patient who has been determined to be incompetent to give medical consent?* Yes No Consent to Treat a Minor:*If the above release is given on behalf of a minor or patient who has been determined to be incompetent to give medical consent. Please list the following reasons below: Name* Date* TeleMental Health Recommendations & Instructions Until further notice, Imagine Behavioral Health will be utilizing Video Conferencing (VC) to provide TeleMental Health Services. Our clinicians will be providing therapy and medical services through a HIPAA-secure application called Zoom. We understand that this is a significant change from traditional services provided at our location, which is why our staff wants to equip you with the following instructions/recommendations for utilizing our new system/services with as few issues as possible: Before the Session Starts ● You will need to schedule an appointment as usual by calling the office at 601-982-5376. You will receive text message reminders as usual prior to your appointment. ● Make sure you have electronically signed the “Informed Consent for TeleMental Health Services” document. You can access this document here: https://www.imaginebh.com/forms/ ● Sign up and download the Zoom app on your laptop, desktop, tablet, smartphone, etc. ● Make sure you have a well-lit, private space to be in where you won’t be distrubed or heard. This may be in a bedroom, home office, or even, if needed, a large closet, basement, or in your car in your driveway. ● If you live with others, you will need to make sure roommates, family members, etc. don’t disturb you. You might consider putting a white noise machine or a small window fan on outside the door of the room you are in.There are also white noise apps available for your phone, as well as videos of white noise on YouTube. ● In most cases, you will be able to utilize Zoom on your smartphone; however, the app’s functionality and features are optimized by using a laptop, desktop computer, or tablet. ● Using earphones plugged into the computer/phone helps maintain privacy and improves sound. ● Make sure all unnecessary web-browsers are closed and that no one else in your home is using the Wi-Fi for streaming. Beginning a Session ● You will receive an email or text message (preference specified with office staff) that contains a link to the video conference. Upon clicking the link, you will be transferred to a virtual waiting room until your clinician is ready to conduct your session. ● Once your session begins, turn on video and audio by pressing the camera and microphone icons on the bottom left of your viewing screen. Troubleshooting/Operating Zoom ● Make sure your volume is up and that your video and microphone are on. This may not happen automatically. ● Further troubleshooting and operating instructions are provided in the “Informed Consent for TeleMental Health Services” document, and on our Zoom information sheet. TeleMental Consent* By checking this box I confirm that I have read and consent to the terms and limitations of the Telehealth Agreement with Imagine Behavioral Health.By typing my name, this represents I am agreeing to all of the terms of the TeleMental Health Services** Today's Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.