CONSENT FORM
Telehealth Appointments:
We will be using a HIPPA compliant platforms with a BBA agreement and ongoing efforts on my part to make sure our meetings have the maximum security to my knowledge and the recommendations of the Board of Social Workers and state laws.
Virtual appointments are convenient and sometimes a strategic step to our healing process. At some point, you and I will noticed that gathering virtually is no longer meeting the innate need for connection and authenticity. As we meet, we will evaluate and reevaluate how you can fulfill this need in a way that is sustainable and accessible.
Please make sure you prepare for our virtual sessions before hand. In the following scenarios, your sessions will be cancelled with a $100 cancellation fee:
I DO NOT CONDUCT SESSIONS WHILE DRIVING. This puts your life in danger and robs us of the opportunity of therapeutic benefits.
If you'd like to include someone in your session, please let me know ahead of time. The safety of our space is violated when people interrupt the session or in the background.
Confidentiality:
I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of Telehealth services. The nature of electronic communications technologies, however, is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for Telehealth sessions and having passwords to protect the device you use for Telehealth).
Client Rights
Clients can withdraw or withhold this consent at any time. Any action will not affect the future treatment of patients. Clients can ask any question regarding telehealth services, treatment process, and appointments before, during, or after the treatment.
You have the right to request your clinical notes, treatment plan and treatment outcome at any point of your treatment or after your treatment.
Cancellation Policy
You understand that your appointment must be canceled at least 24 hours in advance or you will be responsible for a cancellation fee of $100. After 15 minutes of no-show, your appointment will be cancelled and you will be responsible for the cancelation fee of $100.
Email and Text
I consent to receive text messages or emails from Nabi De Angulo (my “Provider”) and their agents on my cell phone or other devices. I understand that text messages and emails sent by Provider may include appointment reminders or changes in previously scheduled appointments, or may provide advice or education.
Provider does not charge for this service, but I understand that standard text messaging rates may apply as provided in my wireless plan. I have been advised that I may contact my carrier for pricing plans and details.
I understand that I may revoke my request for further communications via text or email at any time by notifying my Provider in writing. However, if I continue to communicate with my Provider via text or email, my Provider can assume that my consent remains valid.
Because e-mails sent over the Internet or texts sent over the control channel without encryption are not secure, I understand the risks associated with e-mail and text messaging, including, without limitation, that e-mails and text messages could be intercepted by unknown third parties; e-mail content can be changed without the knowledge of the sender or receiver; backup copies of e-mail may still exist even after the sender and receiver have deleted the messages; and e-mail can contain harmful viruses and other programs.
My Provider has recommended that I delete all text messages or emails as soon as possible after reviewing them to limit any unauthorized exposure.
Private Policy and Confidantiality
State and federal laws protect the confidential nature of the therapist-client relationship. Clinical information will not be released to anyone without prior written consent to do so by the client (or the guardian-parent of a minor). Interaction between client and therapist will be limited to therapeutic sessions provided by Awayu Healing LLC as detailed by the Code of Ethics.
Text and email communication will be limited to billing and scheduling questions and may be done so with awayhealing@gmail.com and (856) 425-2733. Please see email/text consent agreement.
Exceptions to confidentiality and client information may include:
A therapist must take appropriate action when there is a danger to the client or to another individual at the client’s hands. State law mandates that suspected neglect or abuse of a child, of an elderly individual, or of a disabled individual must be reported.
When ordered by a court to do so, a therapist may testify or release client records. However, no release of information or testimony is given in response to a subpoena without the client or client guardian’s written authorization unless required by law to do so.
Consultation with other health care professionals may be necessary at some point in time. Where possible, identification of clients is withheld. However, there are times when exchange of information is necessary. Case material is often used for training, for research, and for other academic endeavors but client identification is always removed. Any other release of information must come with the above listed written approval.
Social Media
Your privacy is important to me. To ensure confidentiality, I will not accept client’s friend requests on personal social media cites (facebook, IG, twitter, etc). You are welcome to follow our agency’s social media pages @awayuhealing but I do not respond to messages on social media as they are not HIPPA compliant and may threaten your confidentiality. Please refer to our website awayuhealing.org for other forms of communication.
Acknowledgement and Agreement
I have read and understand the information provided above, and understand and agree to the terms in this Agreement, including costs of Services, payment methods and cancellation policy. Any questions I had have been answered.
By writing your name below you agree to electronically sign to this agreement: