Policies Packet

Informed Consent for Hybrid Treatment 7.21

Please initial each statement below to indicate that you have read, understand, and consent to treatment.

I have been provided access to and have read the Texas State Counseling Center’s Scope of Practice and Important Information for Clients documents.

I understand that counseling is a collaborative process between clinician and client, the results of which cannot be guaranteed.  There are many different methods that may be used to support the concerns I hope to address, and I agree to make an active effort to work on these issues both during and between counseling sessions.  I also understand that counseling can have both benefits and risks.  Since counseling often involves discussing unpleasant aspects of life, I may experience uncomfortable feelings such as sadness, guilt, helplessness, and anger.  However, counseling frequently has significant benefits which I may also experience, such as improved relationships, solutions to specific problems, and a reduction in feelings of distress.

_____  Initial your understanding and consent

During my initial appointment, the clinician will recommend the most appropriate sources of support for me.  This may include individual counseling, group counseling, referral support, on-line, other university and/or community resources.  The Counseling Center utilizes a brief individual counseling model (detailed in the Scope of Practice).  Appointments are typically scheduled every 2 to 3 weeks.  The estimated number of sessions and frequency will be discussed with my assigned clinician.  Group counseling offers weekly support and skills development and can be utilized each semester of enrollment as assessed to be appropriate upon consultation with the group facilitator(s).  Our referral specialist can assist students in identifying sources of weekly, long-term, intensive, or specialized therapeutic support in the community.  The Counseling Center also offers an easy-to-access, online program called Therapy Assistance Online (TAO) that helps students develop skills and coping strategies. 

_____  Initial your understanding and consent

I understand that the Counseling Center operates as an agency made up of many clinicians and that I am a client of the agency.  A progress note will be created about each individual and group counseling contact and clinicians within the Counseling Center have access to my Counseling Center record.  My clinician will be assigned/reassigned by the Counseling Center based on best match and availability.  In addition, to provide the most effective and comprehensive services, the Counseling Center clinical staff may consult with health care providers in the Student Health Center when I have been or will be referred from one center to the other.  My written consent is required for the Counseling Center to share a portion of my record with the Student Health Center.

_____  Initial your understanding and consent

I understand that all aspects of my participation in counseling at the Counseling Center are confidential as required by federal and state law.  I have been informed there are exceptions to confidentiality which may require my clinician or the Counseling Center to disclose confidential information without my permission (e.g., to report suspected child, elder, or mental health provider abuse; to obtain assistance from medical or law enforcement personnel if I am judged to be a danger to myself or others; in response to a subpoena or court order; and other circumstances as required or allowed by law).

_____  Initial your understanding and consent

I understand that if I have any concerns about services I receive from the Counseling Center I can discuss them with my clinician.  If needed, I can further address my concern with the Counseling Center Director.  If either cannot satisfactorily address my concern, I may submit the complaint to the Assistant Vice President for Student Affairs.  If no satisfactory solution is reached at the Asst. VP level, I may submit a complaint to the appropriate licensing board.  Information pertaining to your clinician’s professional license and how to contact applicable licensing boards can be found on the Counseling Center’s website at www.counseling.txstate.edu/about/staff.

_____  Initial your understanding and consent

Hybrid Services (In-Person and Telemental Health)

The Counseling Center provides enrolled students that reside in Texas the opportunity to participate in services via two modalities, in-person or by Telemental Health (TMH).  TMH refers to counseling sessions that occur via phone or confidential video platform.  For students residing outside of Texas, the Counseling Center can provide only brief consultation and support planning due to state licensing requirements.  I understand I am providing consent for both modalities; the clinician(s) at the Counseling Center will provide modality options that best fit my needs, and the modality may change during the course of my counseling.  Each modality has different requirements that will be outlined further in the following sections.

_____  Initial your understanding and consent

In-Person Services

When I engage in in-person services at any point, I understand and acknowledge the following points during a public health crisis (like COVID-19):

• The Counseling Center is taking steps to reduce the risk of spreading viruses (including COVID-19) within the office and has posted these efforts on the website and in the office.  I can ask Counseling Center staff questions about these efforts or about receiving in-person services at any point.
• I understand and agree that by coming to the Counseling Center, I am assuming the risk of exposure to viruses (such as COVID-19, the flu, or other public health risks). This risk may increase if I travel to the Counseling Center by public/shared transportation.
• My clinician can choose to wear a mask for their health and wellness.  I have the option of wearing a mask as well and may be strongly encouraged to wear a mask if a public health incident is underway.
• To protect the health and wellness of the Counseling Center staff and other students, I agree to call the office to cancel my appointment or request to proceed using TMH, if I or someone in my social, living, learning, work, or other close environment has symptoms of or tests positive for COVID-19 OR I have two (2) or more of these symptoms:
• A fever of 100 Fahrenheit or more, chills, or sweating;
• Shortness of breath, difficulty breathing, or new or worsening cough;
• Sore throat, or new loss of taste or smell;
• Muscle or body aches, headache, or fatigue;
• Congestion or runny nose; or
• Nausea, vomiting, or diarrhea.

Cancellations due to these symptoms will not be counted towards the attendance policy. 

• I understand and agree that if the Counseling Center staff has reason to believe I am exhibiting such symptoms, I will be required to leave the office immediately and the Counseling Center staff may follow up with me via phone to check in with me.  I understand and acknowledge I may use Student Health Center services for medical screening and care. 
• I understand and acknowledge that should a Counseling Center staff member test positive for COVID-19, I will be notified in order to take appropriate precautions. 
• I understand and agree that should circumstances warrant, my assigned clinician may make a recommendation to proceed using TMH.  If TMH is not my preferred method of treatment, I understand and agree that I will be provided with community referrals.

_____  Initial your understanding and consent

When receiving in-person services I understand and agree I will:

• Enter the Counseling Center no more than ten (10) minutes before my scheduled appointment time. 
• Adhere to the safe distancing precautions (both visual and verbal) set up in the Waiting and counseling rooms.
• I also understand and agree that the Counseling Center may change precautions based on university, local, state, or federal orders or guidelines and that the Counseling Center will communicate any necessary changes.  If there is a resurgence of the pandemic or if other health concerns arise, counseling services may be only provided through TMH. The Counseling Center will discuss any concerns and will provide community referrals as needed. 

_____  Initial your understanding and consent 

If I receive in-person services I understand and expressly consent to public health contract tracing notifications if I or others in the Counseling Center suite with whom I have had close contact test positive for COVID-19 or any other infection where the Counseling Center is required to notify local health authorities of such exposures. If this report is required, the Counseling Center will only provide the minimum information necessary for data collection and will not provide information about the reason(s) for my visit(s), unless otherwise required by law.  I agree to such disclosure without any additional signed release.

_____  Initial your understanding and consent

Telemental Health Services (TMH)

If I engage in TMH at any point, I understand the following points:     

• Similar to in-person counseling, the results of TMH cannot be guaranteed or assured.
• I am not required to use TMH and have the right to request other service options or withdraw this consent at any time.
• I can ask my assigned clinician or any Counseling Center staff questions about TMH at any point. 
• TMH services may not be appropriate or the best choice of service.  My clinician may determine TMH is not an appropriate treatment option and discuss alternative treatment options if at any time my condition changes or TMH presents barriers to treatment.
• I understand the Counseling Center uses Zoom Telehealth or an application via Therapy Assistance Online (TAO) and all video conferencing platforms are HIPPA compliant. 
• TMH services are conducted and documented in a confidential manner according to applicable laws in similar ways as in-person services. However, I understand there are additional risks including:
• Sessions could be disrupted, delayed, or communications distorted due to technical failures.
• TMH may reduce visual and auditory cues and increase the likelihood of misunderstanding one another.
• In very rare cases, security protocols could fail, and my confidential information could be accessed by unauthorized persons.

_____  Initial your understanding and consent

I understand and acknowledge the following TMH requirements:

• Based on my clinician’s licensure requirements I must only engage in TMH sessions when I am physically in Texas. I understand my clinician will confirm my location at each session.
• My clinician and I will engage in sessions only from a private location where I will not be overheard or interrupted.
• My clinician and I agree to only use a device and/or wi-fi connection that is not accessible to the public and ensure that the device has updated operating and anti-virus software.
• My clinician and I will not record any sessions.  In the case of clinicians who are under supervision, a separate informed consent related to recording and supervision will be provided.

_____  Initial your understanding and consent

Consistent with national standards in TMH, to engage in TMH I must provide contact information for an emergency contact IN MY LOCATION during sessions.  During treatment, the Counseling Center can contact my emergency contact if I am in crisis and my clinician is unable to reach me, or in the case of emergency during a session:

Emergency Contact’s Name:

Relationship to Student:

Emergency Contact’s Address:

Emergency Contact’s City/State/Zip:

Emergency Contact’s phone number:

Contacting the Counseling Center

Please make sure the Counseling Center has a current phone number at which you can be reached.  If you need to reach your clinician between sessions, you may call the Counseling Center at 512-245-2208 during normal business hours (M-F, 8am-5pm, except during university holidays).

If you choose to email your clinician, you acknowledge that email:

• Is not a secure form of communication,
• Should only contain appointment-related communication, and
• Is not continuously monitored, so you will not get an immediate response.

Your clinician will not send private information over email.

_____  Initial your understanding and consent

If I am in crisis outside of normal hours, I agree to do one of the following:

• Call 911 or go to my nearest emergency room in case of a medical or mental health life threatening emergency
• Call the Counseling Center and choose the option to be connected to a mental health provider for crisis assessment and planning
• Call my local county suicide prevention hotline and indicate I am a Texas State student (San Marcos, Avail Crisis Hotline: 1-877-466-0660 or Round Rock, Bluebonnet Trails Crisis Hotline: 1-800-841-1255)
• Call the National Suicide Prevention Lifeline (1-800-273-8255)
• Use a Crisis Text Line- Text HOME to 741741 or for BIPOC students- Text STEVE to 741741
• Contact the local mental health authority in
• county of my location (https://hhs.texas.gov/services/mental-health-substance-use/mental-health-crisis-services)

_____  Initial your understanding and consent

I have read and I understand my rights and responsibilities as I enter into a counseling relationship at the Texas State University Counseling Center.  I agree to show up for (or appropriately cancel) scheduled appointments, to consider medical/psychiatric consultation if recommended, and to follow a crisis safety plan as needed.  If I am assessed to be in crisis, the Counseling Center may contact any persons who can help facilitate my care (e.g., other professionals, my emergency contact, family or friends identified as support resources, referral sources, etc.).  If I have any questions about my rights, responsibilities, privacy, and/or the operations of the Counseling Center, I may ask my assigned clinician or another clinical staff member.

_____  Initial your understanding and consent

Summary Acknowledgements and Informed Consent: 

• I have read, acknowledge, and understand the information provided herein and am aware I can ask Counseling Center staff additional questions, at any time.
• I have received and acknowledge the information provided in the Scope of Practice and Important Information for Clients.
• I am aware of the risks associated with in-person services, agree to follow all Counseling Center safety practices policies, and provide my informed consent for in-person services.
• I provide my informed consent to use Telemental Health when my clinician and I agree it is a beneficial modality.
• I understand and agree that my clinician may determine in-person and/or TMH are not appropriate treatment options and that I may be provided alternative treatment options or referrals at any time.

_____  Initial your understanding and consent

Enter your TXST ID number (A0…):  ________________________

Attendance Agreement- Rev 8.21

Please initial each statement below to indicate you have read, understand, and consent to this Agreement.

Due to the heavy demand for individual counseling and out of respect and fairness to other students who wish to receive services from the Counseling Center, you must call 512-245-2208 to cancel or reschedule your appointment at least 1 day (24 hours) in advance of your scheduled appointment time. 

_____  Initial your understanding and consent

Missing appointments negatively impacts access to Counseling Center services for all students.  The following are criteria that constitute a “no show”:

• Missing your scheduled appointment
• Failing to call and cancel at least 2 hours prior to your appointment
• Arriving 20 minutes or more after your appointment time. 

_____  Initial your understanding and consent

If you no show 2 appointments in the same semester, we are unable to keep any scheduled appointments or schedule another appointment for the remainder of the semester.  You may request referral information.  You may be eligible for counseling services the next semester in which you are enrolled.

_____ Initial your consent

Email reminders are available to help you to remember your appointment.  If you are having difficulty remembering or attending your appointments, please talk to your clinician.  They can work with you to try to address the concern.

_____ Initial your consent

I acknowledge I have read this Agreement and will abide by the conditions set forth in the Agreement.

Enter your TXST ID number (A0…):  ________________________

Communications Agreement- 8.21

To facilitate your counseling experience, you are required to provide the Counseling Center with consent to reach you via ONE form of communication (phone, email, or text). 

_____  Initial your understanding and consent

Phone and Voice Mail

Clinicians will identify their name and that they are calling from Texas State.  If they reach you they will clarify the purpose of their call.  If they leave a voice mail message, they will request you call 512-245-2208 but will not identify themselves as being part of the Counseling Center. 

To opt-out of phone calls at any time, call the Counseling Center at 512-245-2208 to update your file.

_____  Initial your understanding and consent

E-mail

E-mail is not a secure form of communication and Counseling Center staff will not provide personal or counseling related information in e-mail.  E-mails will come from either a general center mailbox or your clinician’s TXST email.  Staff will limit their use of e-mail communication to the following purposes:

•             To provide you with information about your appointment

•             To notify you of appointments not attended or canceled late that impact your access to therapy based on our Attendance Agreement

•             If we are unable to reach you by phone and need you to call the center

•             To acknowledge your e-mail message

•             To provide resources with your verbal consent

Appointment reminders will be sent to your Texas State e-mail address (which you can automatically forward to another preferred e-mail address, if desired). 

To opt-out of e-mail messages at any time, call the Counseling Center at 512-245-2208 to update your file.

_____  Initial your understanding and consent

Text Messages

The Counseling Center can send text messages to:

• Remind you of upcoming appointments
• Request you call the Counseling Center for assistance
• Inform you that you are missing your appointment 

Because text messages are not a secure form of communication, personal or clinical information will not be included in any text communication and the Counseling Center will not be able to receive text messages or replies.  Text message reminders will come from 512-598-6410.

Depending on your mobile plan, texts from the Counseling Center may incur a charge on your monthly bill.  Some cellular phone bills may also include a list of phone numbers from which you received text messages.

To opt-out of text messages at any time, call the Counseling Center at 512-245-2208 to update your file.

_____  Initial your understanding and consent

My TXST ID and Date of Birth below indicate I have read, understand, and consent to the above.

Enter your TXST ID number (A0…):  ________________________