Consent to Telemental Health: Support Group

Information, Authorization, and Consent to Telemental Health: Support Group
  • This document indicates your consent to participate in distance-oriented support group sessions, otherwise known as telehealth, which take place over a HIPAA compliant telehealth 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 the Cancer Support Community Valley/Ventura/Santa Barbara. 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:
    We acknowledge that for some people getting to a physical Cancer Support Community facility is not possible. Telehealth can be utilized in circumstances that prevent you from in-person group support. 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 myself and other support group members 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.
    • If there is a loss of connection, I will refer to the In Case of Technology Failure item below.
    • 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 telehealth 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 Cancer Support Community Valley/Ventura/Santa Barbara 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. Cancer Support Community Valley/Ventura/Santa Barbara requires an Emergency Contact Person who your facilitator may contact on your behalf in a life-threatening emergency only. Please enter this person’s name and contact information.
  • By completing and submitting this consent electronically, I hereby indicate my compliance with the above stated expectations. I reserve the right to revoke my consent, in writing, at any time. I may specify the date, event or condition on which this consent expires. If none is stated, and if no prior notice of revocation is received, this consent will expire one year after the date it was initiated. Please enter your name and date below indicating that you have read and understand the contents of this form, you agree to these policies, and you are authorizing your facilitator to utilize the Telemental Health methods discussed.
  • Date Format: MM slash DD slash YYYY
  • If you need help completing this form or have any questions, please contact us at