Pro Bono Telehealth for Front Line Health Care Providers Facing Covid-19: OC CAMFT Chapter
Pro Bono Counseling for Front-line Healthcare Workers Facing COVID19: OC Chapter
Thank you for volunteering your time to this worthy cause!

**Please read the following information before responding to this survey.**

Please note that many healthcare workers may only be able to attend short appointments, for example 30 minute appointments. We encourage all volunteers to offer that format if possible; there is a question below where you can indicate your willingness to do short sessions.

Please also note that this is intended for short-term treatment during this crisis. Healthcare workers who use this service may choose to continue into longer-term treatment if it is offered by the therapist, but this is not expected of them. Please be mindful that the frame is short-term treatment and that patients/clients should not be asked, explicitly or implicitly, to commit to a longer time frame.

Please note that this project is a tool to help healthcare workers find pro bono treatment within the private practices of mental health clinicians. You must be licensed in California and already have a private practice with the appropriate licensing and liability insurance. You will be seeing the patient in that frame, under your own liability insurance, in keeping with professional and ethical principles, and in keeping with all regulations, including insurance-related and documentation-related regulations, under which you practice.

Finally, please note that the information you provide will be shared with the potential patients/clients and with intermediaries who will assist in distributing this information to the potential patients/clients (these may include hospital administrators and possibly state and local authorities if they choose to support the dissemination of this project). The information will be conveyed on a website, which potential patients/clients will access via a link that is provided to them. We will not have control over whether this link is shared with others, and therefore you should assume that the information you provide may become public.

You may choose to have your information removed from the website at any time; simply email us indicating you would like your information removed. Please let us know when you have no further availability so that we can remove your information. If you later have availability, you may contact us to be re-added.

If you have any questions or concerns, please email

Rachelle Marshall, Past President OC CAMFT
Sign in to Google to save your progress. Learn more
By clicking here, I am attesting that I am licensed to provide psychotherapy in California, that I currently practice in a private practice setting with the necessary liability insurance and in keeping with professional and ethical principles as well as all relevant regulations, and that my practice is located in the Orange County Area. * *
By clicking here, I am attesting that any patients/clients that locate my services through this tool will be legally and ethically considered my private patients/clients as regulated by CA state laws, and all responsibility for ethical conduct and clinical liability is my own. *
By clicking here, I am attesting that I understand that this platform is a tool to help healthcare workers locate pro bono services. It is not a referral service. All appointments are scheduled between therapist and patient/client. The platform does not collect any information about treatment pairings or treatments. No clinical information shall be shared with the project leaders, and no clinical information shall be emailed to the project email address or to the leaders' email addresses, all of which are not HIPAA-secure. *
Clear form
Never submit passwords through Google Forms.
This form was created inside of OCCAMFT. Report Abuse