Support Group Application & Telemental Health Consent

Information, Authorization, and Consent to Telemental Health: Support Group
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
    There is great respect for confidentiality at Cancer Support Community Valley/Ventura/Santa Barbara (CSCVVSB). Very little that goes on in the groups becomes public knowledge – not because of a promise or guarantee by CSCVVSB but because of the innate integrity of the participants, the awareness of the harm that gossip can do, and an implied, unspoken, well-accepted agreement among the participants. We recognize that there is a stress-related factor when secrets are held onto. We encourage you to let go of that stress. However, if it is very important to you that a specific fact not be revealed, it is best not to speak about it in group. There is no guarantee of confidentiality made by CSCVVSB or anyone associated with CSCVVSB.
    I wish to join a Support Group at CSCVVSB. I have attended an orientation and I have read the statement on confidentiality at CSCVVSB. Additionally, I AM AWARE AND UNDERSTAND:
    • That CSCVVSB adheres to professional, legal, and ethical standards of confidentiality established by professional organizations and state law. Legal and ethical exceptions to confidentiality include: a clear or present danger to harm oneself or another, knowledge of the abuse or neglect of a minor child, elder or dependent/incapacitated adult, or responses to a court subpoena or as otherwise required by law.
    • That CSCVVSB reserves the right, at its sole discretion, to refuse or discontinue the privilege of use of its facilities or services to any person.
    • That CSCVVSB does not provide medical advice or assistance of any kind.
    • That I do not have any communicable diseases such as hepatitis or tuberculosis, and if I have a cold or flu, I will not attend a group meeting.
    • That I will not share other group members’ contact information with anyone outside the group.
    • That sometimes it is difficult to understand how groups can be helpful, and therefore, I will try to attend at least three (3) meetings before deciding if a group is not for me (if that is the case).
    • That I do not have any communicable diseases such as hepatitis or tuberculosis, and if I have a cold or flu, I will not attend a group meeting.
    • That CSCVVSB’s Support Groups are particularly beneficial during times of transition—at diagnosis, during treatment, as treatment ends and “life after treatment” begins, recurrence, etc, and are not intended to be a place where people land indefinitely.
    • That CSCVVSB’s Weekly Support Groups are to provide emotional support and hope for people who are actively involved in the day-to-day fight for recovery. I, therefore, agree that if and when I have been free of the physical symptoms of cancer and its treatment for a period of eighteen (18) months, I will notify the facilitator of my group and will voluntarily leave the group.
    • That, for the same reason, I, as a caregiver (a support person), agree that if and when my loved one with cancer has been free of the physical symptoms of cancer and its treatment for a period of eighteen (18) months, I will notify the facilitator of my Caregivers’ (Family & Friends) Group and will voluntarily leave the group.
    This Section indicates your consent to participate in distance-oriented support group sessions, otherwise known as telemental health, which take place over a HIPAA compliant telemental health platform, Zoom. Further, this document is designed to inform you about what you can expect regarding confidentiality, emergencies, and several other details during group participation as it pertains to telemental health at CSCVVSB. Telemental health is the mode of delivering group counseling services via technology-assisted media, such as telephone (landline and mobile devices), video conferencing, internet, tablet, PC desktop system or other electronic means using appropriate encryption technology for electronic health information.

    Limitations of Telemental Health: Telehealth can be utilized in circumstances that prevent you from CSCVVSB’s in-person programs and services. Please be aware that there is a risk of misunderstanding group members when communication lacks visual or auditory cues. There may also be a disruption to the service (e.g., phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of group interaction. By Signing This Consent, You Understand and Agree to the Following:
    • First and foremost, protecting my and other support group members privacy is important. Therefore,
      • I will find a private and protected space for all group sessions.
      • During group, no one else will be present in the room.
      • If a protected and private space is not available, I will minimize the presence of other people or animals in the space, and ensure to use a headset or ear buds during the group sessions to protect other members’ privacy.
      • I will not share the online support group link with anyone in any case.
    • To avoid distractions and show respect for other support group members,
      • I will log in on time.
      • I will solely focus on the group and not engage in any other activities during the group sessions.
      • I will not accept other phone calls, texts, and emails or engage in web surfing during our sessions.
      • Prior to joining an online group, I will obtain a reliable Internet connection and necessary devices and use them all the time.
    • I know how to utilize video conferencing technology and/or agreed upon technology-assisted devices.
    • I understand the limitations of telemental health and it is not a complete substitute to the programs offered at the Cancer Support Community Valley/Ventura/Santa Barbara.
    • I understand that a telemental health support group has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
    • I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
    • I understand that my support group facilitator can discontinue the group if it is felt that the videoconferencing connections are not adequate.

    In Case of Technology Failure:
    During a telemental health support group, there could be a loss of phone or Internet connection. If you get disconnected from a video conferencing group, end and restart the session. If you are unable to reconnect within ten minutes, please email the facilitator for instructions.

    In Case of an Emergency:
    If you have a mental health emergency, you are encouraged not to wait for communication back from your facilitator, but to do one or more of the following:
    • Call Lifeline at (800) 273-8255 (National Crisis Line)
    • Call 911
    • Go to the nearest emergency room
    You understand that if you are having suicidal or homicidal thoughts, experiencing symptoms of psychosis, or in a crisis that we cannot solve remotely, your facilitator may determine that you need a higher level of care and telehealth services are not appropriate. CSCVVSB requires an Emergency Contact Person who your facilitator or other staff members may contact on your behalf in a life-threatening emergency.
  • By completing and submitting this consent electronically, you are indicating that you have read and understood the contents of this form, you agree to these policies, and you are authorizing CSCVVSB to utilize the telemental health methods discussed. I HAVE READ THE ABOVE STATEMENTS AND I AGREE TO ABIDE BY THEM.
  • MM slash DD slash YYYY
  • If you need help completing this form or have any questions, please contact us at