Consent for Participation in Virtual Expressive Arts Workshop
This form serves as informed consent for individual telehealth art therapy service through Solstice Healing Arts Collective. Please read fully and complete this form.

I UNDERSTAND AND CONSENT TO THE FOLLOWING:
- Under Michigan Law “Telehealth” is defined as the use of electronic information and telecommunication technologies to support or promote long-distance clinical health care, patient and professional health-related education, public health, or health administration. Telehealth may include, but is not limited to, telemedicine. A “telehealth service” means a health care service that is provided through telehealth.

- 1.The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; expressed threats of violence or harm to myself; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.

- 2.I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

- 3.I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the therapist, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Solstice Healing Arts Collective does not use a HIPPA compliant secure software to deliver telehealth. Solstice Healing Arts Collective members are committed to protecting the privacy of our clients, and take the necessary efforts to deliver services in alignment with HIPPA rules.

4.I understand that if my Therapist believes I would be better served by another form of intervention (e.g., face-to-face services, a different form of therapy), I will be referred to a mental health professional associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may not improve, and in some cases may even get worse.

5.I understand the alternatives to art therapy through telehealth as they have been explained to me, and in choosing to participate in telehealth, I am agreeing to participate using video conferencing technology. I also understand that at my request or at the direction of my therapist , I may be directed to “face-to-face” psychotherapy.

6.I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.

7.I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my counselor in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-clinical personnel to leave the telehealth room, and/or (3) terminate the consultation at any time.

8.I understand that my express consent is required to forward my personally identifiable information to a third party

9.I understand that I have a right to access my health information and copies of my therapy/medical records in accordance with the laws pertaining to the state in which I reside.

10. By signing and completing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based therapetuic services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area. If i am unable to do so in case of an emergency, the group facilitator will contact my emergency contact listed here on my behalf


Email address *
Emergency Contact Name and Number *
Your answer
I give permission for my artwork created during art therapy telehealth treatment to be photographed for the purposes of treatment records. Photographs of my artwork made in telehealth delivered art therapy for the purpose of treatment records will be kept confidential unless identified below. I give permission for photographs of my artwork created in telehealth delivered art therapy to be used for educational and research purposes. I understand that this material may be used as research contributions to the field of mental health and art therapy, or for related educational presentations, and/or supervision of other art therapists. I understand that my identity will remain confidential unless otherwise agreed upon in writing. I give permission for photographs of my artwork created in telehealth delivered art therapy to be used for promotional purposes (website, advertisement, social media, display). I understand that my identity will remain confidential unless otherwise agreed upon in writing. I have been assured that such artwork or photographic reproductions will be presented in a respectful and professional manner. *
I have read, understand and consent to the terms of this document *
SIGNED FULL NAME *
Your answer
E-mail (if interested in receiving more information about therapeutic offerings from Solstice Healing Arts Collective)
Your answer
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