HAST Telemental Health Form
While we are elearning, we are introducing the ability to teleconference with our HAST school social worker.
Please use this form to give your consent for your child to be able to teleconference with Robin Eldert MSW, LSW, LCSW.
Fill in Today's Date *
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I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.
Enter your name if you hereby consent to allow your student to participate in a telemental health visit with Robin Eldert our HAST Social Worker for counseling. *
Enter your child's name *
I understand the following with respect to telemental health: 1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled. *
Required
2) I understand that there are risk and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. *
3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law. *
4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI)also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, danger to self or others; I raise mental/emotional health as an issue in a legal proceeding). *
5) I understand that if my child is having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required. *
6) I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please email me at reldert@hammondacademy.org to discuss since we may have to re-schedule. *
I understand that Robin Eldert may need to contact my child's guardian and/or appropriate authorities in case of an emergency. *
Emergency Protocols: I need to know your child's location in case of an emergency. You agree to allow your child to inform me of the address where they are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life threatening emergency only. This person will only be contacted to go to your child's location or take them to the hospital in the event of an emergency. *
Enter Guardian's Phone number and Email address *
Anything new or recent you would like Robin Eldert to know about your child. Explain what issues your child is having. *
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