Electronic Communication Agreement | Children's Advocacy Center

Step 1 of 4

CONSENT TO TREAT AND PERMISSION TO RELEASE INFORMATION
I understand that the Children’s Advocacy Center of the Bluegrass (CACBG) is providing a mental health assessment and treatment service(s) to my child or the child in my custody.

I understand that there are no certain outcomes from these services and that individual experiences with treatment may vary. It is important to work with the therapist to decide when therapy goals have been reached and when services shall be terminated, but overall I understand that I do have the right to stop therapy services at any time.

In giving consent to the CACBG to provide these services to my child or the child in my custody, I am aware that the CACBG has a duty to protect my confidentiality except where the law requires disclosure of certain information.

There are several situations in which the Center cannot assure confidentiality including:
1. The Center has a duty to report the abuse or neglect of a dependent adult and/or domestic violence offenses to the Cabinet for Health and Family Services;
2. The Center has a duty to report any instance of child neglect, exploitation or abuse to the Cabinet for Health and Family Services and/or law enforcement;
3. The Center has a duty to report any threats against persons to the intended victim and to the police;
4. The Center has a duty to release information to agencies or persons with a need to know when a client is in need of hospitalization; and
5. When a client introduces personal mental health issues in court proceedings, then the client waives confidentiality.
Understanding all of the above possible waivers of confidentiality regarding information about my mental health condition and treatment, I give consent to CACBG to provide assessment and treatment services to my child or the child in my custody.

In giving permission for services, I also give consent to release information from the CACBG record of my child or the child in my custody to our service region’s Multidisciplinary Team stated below. The release refers to all relevant in- formation pertaining to the abuse of the child named below for the purpose of assisting in coordinating services. My consent includes the permission for CACBG staff to utilize electronic communications such as email when communicating with community partners listed below. I may revoke this consent at any time I chose by informing the Center.

Multidisciplinary Team Members: Commonwealth Attorney’s Office, Kentucky State Police, Government Police Department, Cabinet for Health and Family Services Department for Community Based Services, bluegrass.org, Center for Women, Children and Families, Court Appointed Special Advocates, and Guardian Ad Litem.
Patient Information
Child's Name:*
Child’s Parent/Guardian Signature:*
Witness Signature:
Relationship To Patient:*
Date*
MM slash DD slash YYYY
Federal rules prohibit any party from making further disclosure of this information “unless further disclosure is expressly permitted by the written consent of the person to whom it pertains” or is otherwise permitted by 42 CFR Part 2.

Telehealth Mental Health Treatment Patient Consent Form
By signing this form I am agreeing to utilize telehealth services as a means to receive mental health treatment from The Children’s Advocacy Center of the Bluegrass (CACBG), for myself and/or the child in my custody. I understand I will also sign and agree to CACBG’s therapy consent form, policies and procedures form, and electronic communication form before starting telehealth services. I understand engaging in telehealth services requires my family to have Internet access and a computer/phone with audio and camera. I understand doxy.me is the only platform offered by CACBG for telehealth services (HIPPA-compliant platform with a business associates agreement). I understand the nature of telehealth services is utilization of real-time video-streaming technology between client and clinician.

I understand CACBG therapists will be providing all telehealth sessions inside the clinical office at CACBG. The clinical office setting ensures CACBG clinicians are conducting sessions through a secured Internet connection, with Windows 10 security system, and inside a confidential space. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth communication, and all existing confidentiality protections under federal and Kentucky state law apply to information disclosed during this telehealth communication (see informed consent form and electronic communication form).

All existing laws regarding your access to medical and mental health information and copies of your medical records apply to this telehealth communication. Please note, your telehealth communication will not be recorded and stored. Additionally, dissemination of any client-identifiable images or information for this telehealth communication shall not occur without your consent. Documentation of telehealth therapy services will be completed by the clinician through paper records and/or CACBG’s secured online database.

I understand CACBG is not responsible for any fees related to my family’s Internet costs or data overages as a result of using telehealth services. I am responsible for communicating with the therapist if there is a change in my ability to continue engaging in telehealth services. I understand I can terminate utilization of telehealth therapy services at any time without affecting my right to future care or treatment that is offered by CACBG, or risking the loss of any program benefits to which I’m entitled. I can communicate with my clinician about other mental health services and providers in the community if CACBG services cannot meet my family’s therapy needs.

I understand I must complete an interruption of services plan, an emergency plan, and a termination plan with my CACBG clinician. The plans will be completed during a telephone screening call and during my first session of telehealth services with CACBG clinician. The plan will include agreeing to be at the physical address I’ve provided below for each scheduled telehealth session. I understand that telehealth may not be the appropriate platform for my mental health needs, and the CACBG clinician has the right to terminate this service and recommend other services if needed.

I agree any dispute arriving from the telehealth communication will be resolved in Kentucky, and that Kentucky law shall apply to all disputes. I have been advised of all the potential risks, consequences and benefits of telehealth communication (see electronic communications form). I have had the opportunity to ask questions about the information presented on this form and all other therapy intake forms provided by CACBG. All of my questions have been answered and I understand the written information provided above.
Client's Name:*
Date Of Birth:*
MM slash DD slash YYYY
Signature of Client/Guardian:*
Date*
MM slash DD slash YYYY
Witness Signature:
Date
MM slash DD slash YYYY
Client Address:*
Where they will be for each scheduled telehealth therapy session:

Street Address Address Line 2 City State ZIP Code

The Children’s Advocacy Center of the Bluegrass Electronic Communication Agreement
Now, more than any other time in history, electronic communications and electronic services are crucial to providing effective and safe services to families. However, there are potential risks to families ’ protected health information (PHI) when utilizing electronic communications and services. Please review The Children ’s Advocacy Center of the Bluegrass ’ (CACBG) policies about electronic communications before agreeing to engage in these types of services with CACBG staff members.

EMAIL:
CACBG considers our role to protect your family ’s PHI highly important. Our email service, kykids.org, has an added security program called G Suite Sync. This program ensures we have a business associate agreement and breach insurance for our email transmissions. The email security measures at CACBG help decrease breaches to your PH I, but it is important you understand there are potential risks to breaches of your PHI that we cannot always control or foresee (examples: computer viruses/hacks, human error). It is important you understand the CACBG cannot guarantee the confidentiality and security of email transmissions. It is important that you do your part to secure your PHI when emailing with CACBG staff members as well. A family member may be able to see your emails so you need to be aware that you are emailing at your own risk. CACBG is not liable for breaches of confidentiality caused by yourself or a third party. It is important you do not send CACBG staff members ’ emails related to emergency issues or for matters that require an immediate response. We will read and respond to your emails, but we cannot always guarantee a response time. Emergency or timely issues need to be handled through the telephone or contacting an emergency resource in your community.

TELEHEALTH:
CACBG uses doxy.me platform for telehealth services, which has a business associate agreement and breach insurance for added security measures. However, breaches of your confidentiality and PHI when using telehealth services are still possible such as computer hacks, human error, and third party interference. A CACBG staff member will work with you to review the safeguards we should put in place to maintain confidentiality when engaged in telehealth services, but CACBG cannot be liable for breaches of confidentiality caused by you or a third party when engaged in telehealth services.

SOCIAL MEDIA and CELL PHONE USE:
To protect client confidentiality CACBG requires staff members do not engage in social media friendships with families we work with and/ or share our personal phone numbers with families we work with. We hope you understand.

By signing below you agree you have read and understand CACBG’s electronic communication policies and the risks you take when engaging in electronic services with CACBG staff members. You understand you have the right to revoke this agreement but will need to do so verbally and/or in writing with CACBG staff members.
Name of Client:*
Signature of Client/Guardian:*
Date*
MM slash DD slash YYYY
Witness Signature:
Date
MM slash DD slash YYYY
Email Address*
Please write the preferred email address you agree CACBG staff members can email you as needed, which may include PHI. If you agree a CACBG staff member can email your child directly then please include the child’s email as well.

The Children’s Advocacy Center of the Bluegrass’ Therapy Policies and Procedures
THERAPY SERVICES
Therapy is not intended to be investigative, nor is it the therapist’s role to refute or confirm if sexual abuse occurred. Therapy specifically addresses issues that surround child sexual abuse and trauma that has incurred. Treatment provided by the CACBG is of no fee to families. Treatment interventions may vary in response to presenting needs, but primarily The Children’s Advocacy Center of The Bluegrass (CACBG) mental health services incorporate a Trauma Focused-Cognitive Behavioral Therapy model. Your child and family may be seen for up to 12-18 visits if needed at which time an assessment will be made as to whether further treatment is necessary. Your child may need to be referred to another mental health agency for ongoing therapy services. The average length of family and individual sessions are 50 to 60 minutes. CACBG does not provide emergency services after business hours or on the weekends. If you need emergency mental health services then please seek help at your local emergency room if our center is closed, and/or refer to the safety/emergency plan developed with your therapist.

REQUESTED LETTERS IN CUSTODY DISPUTES
The CACBG is a neutral site where services are provided to children who have been sexually abused. The Center does not take sides in custody disputes. The Center is unable to write letters of recommendation on a parent’s behalf related to custody disputes.

CAREGIVER’S RESPONSIBLITIES
Children must be accompanied by an adult while at the Center. The child’s caregiver must remain on the premises at all times until the child’s therapy session is complete. It is against policy for an adult to drop off a child and return later for the child. The same considerations apply when engaging in telehealth therapy sessions with CACBG therapists. Parents have to agree to be in the home the entire time their child is being seen through telehealth services. Caregivers have to agree to telehealth policies/plans before telehealth services can begin, which will be done with your clinician during the initial telehealth sessions and scheduling calls.
APPOINTMENT SCHEDULING, NO SHOW, AND CANCELLATIONS
Appointments are recommended and scheduled according to individual therapeutic needs. Your therapist will attempt to schedule your appointments when it is convenient for you and your family’s schedule. However, it is not possible for everyone to schedule during his or her desired time each session. If it is necessary to miss school or work for your appointment, we are happy to provide you with a written excuse.

Please call at least 24 hours in advance to reschedule an appointment if needed. In the case of an emergency we realize this may not be possible, but we appreciate that you take the initiative to communicate with the therapist as soon as possible when you know you will be missing an appointment. If you arrive more than 20 minutes late for your scheduled therapy session the appointment will be cancelled (both in person and via telehealth services). It is very difficult to get the necessary work done in such a limited time.

If you are unable to contact the agency before your scheduled visit and you miss the visit, this will be considered a “no show” appointment. Your chart may be closed, or you may lose your preferred standing appointment slot, if you no show two or more times.

We encourage families to take initiative in rescheduling their cancelled and/or missed therapy appointments. However, a staff member will attempt contact with you to reschedule the appointment within one week after your missed/cancelled appointment. If the appointment has not been rescheduled within one month then we will assume you are no longer seeking services and the chart will be closed.

If you or your child are sick or have a fever, please call to cancel your appointment. We want to protect the health of your family as well as other families who may be visiting the Center.

In case of inclement weather conditions, or public health issues in the community, the Center may be closed. Tune in to your local television station for information on business closings.

By signing this form I am confirming that I have been given a copy of the CACBG’s therapy policies and procedures and that I have been able to ask any questions I had related to the policies and procedures. I agree to follow CACBG’s therapy policies and procedures to the best of my ability as the identified caregiver.
Child's Name:*
Child’s Parent/Guardian Signature:*
Date*
MM slash DD slash YYYY
Witness Signature:
Date
MM slash DD slash YYYY

Step 1 of 4

CONSENT TO TREAT AND PERMISSION TO RELEASE INFORMATION

Patient Information

Telehealth Mental Health Treatment Patient Consent Form

The Children’s Advocacy Center of the Bluegrass Electronic Communication Agreement

The Children’s Advocacy Center of the Bluegrass’ Therapy Policies and Procedures

THERAPY SERVICES

REQUESTED LETTERS IN CUSTODY DISPUTES

CAREGIVER’S RESPONSIBLITIES

APPOINTMENT SCHEDULING, NO SHOW, AND CANCELLATIONS

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