The following information is to be completed by the person being served or the person’s authorized representative/parent.
The purpose of this document is to inform you, the client, about many aspects of online gender care consultation services: the process, the potential risks and benefits of services, safeguards against those risks, and alternatives to online services. Please read this entire document before agreeing to the terms and conditions.
1) Possible misunderstandings: The client should be aware that misunderstandings are possible with telephone, text-based modalities such as messaging, and real-time internet chat, because nonverbal cues are relatively lacking. Even with video chat software, misunderstandings may occur due to connection problems causing image delays or less than optimal image quality. If you have never engaged in online counseling before, please have patience with the process and clarify information if you think the consultant has not understood you well. Also, please be patient if the consultant asks for periodic clarification. All sessions and messaging are in English.
2) Turnaround time: Using asynchronous (not in "real time") communication such as email or messaging entails a “lag” of response. The consultant will make every effort to respond to message requests within a 24-hour period. If the client is in a state of crisis or emergency, the consultant recommends the client contact a crisis line or an agency local to the client. Clients may also utilize 1-800-SUICIDE or 1- 800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY).
Hours are Monday - Friday, from 10 AM - 8 PM Pacific Time time, unless otherwise agreed upon.
3) Privacy of the consultant: Although the internet provides the appearance of anonymity and privacy in consultation, privacy is more of an issue online than in person. Mere Abrams, MSW has chosen to use Zoom.us as the software provider for web conferencing, and chat communications between the consultant and clients. The client is responsible for securing their own computer hardware, internet access points, and password security.
The consultant has a right to privacy and may wish to restrict the use of any copies or recordings the client makes of their communications. Clients must seek the written permission of the consultant before recording any portion of the session and/or posting any portion of said session on internet websites such as Facebook, Instagram, or YouTube.
B. Potential benefits: The potential benefits of online gender care consultation services include both the circumstances in which the consultant considers online services appropriate and the possible advantages of providing those services online. For example, the potential benefits of video chat include the convenience for clients to potentially receive services from anywhere once an internet signal and necessary hardware is secured. Text-based chat has many of the same advantages of convenience, feeling reduced scrutiny from the consultant, having time to compose a response, and being able to refer back to the chat log for reference. The benefits of using asynchronous messages may include (1) being able to send and receive message at any time of day or night; (2) never having to leave messages or voicemails; (3) being able to take as long as one likes to compose a message, and having the opportunity to reflect upon it; (4) automatically having a record of communication to refer to later; and (5) feeling less inhibited than in person.
C. Potential risks: There are various risks related to electronic provision of consultation services related to the technology used, the distance between consultant and client, and issues related to timeliness. For example, the potential risks of message based consultation may include (1) messages not being received and (2) confidentiality being breached through unencrypted email, lack of password protection or leaving information on a public access computer in a library or internet café. Messages could fail to be received if they are sent to the wrong address (which might also breach of confidentiality) or if they just are not noticed by the consultant. Confidentiality could be breached in transit by hackers or Internet service providers or at either end by others with access to the client’s account or computer. People accessing the internet from public locations such as a library, computer lab, or café should consider the visibility of their screen to people around them. Position yourself to avoid others’ ability to read your screen. Using cell phones can also be risky in that signals are scrambled but rarely encrypted.
D. Safeguards: Your consultant has selected an account with Zoom.us for chat/ messaging and video communications to allow for the highest possible security and confidentiality of the content of your sessions. In order to benefit from these safeguards, the client is required to download, register and utilize the chat and video software from Zoom.us. Your personal information is encrypted and stored on a secure server in compliance with HIPAA regulations. For ease of use, Mere Abrams, MSW can assist you in downloading Zoom.us. The client is responsible for creating and using additional safeguards when the computer used to access services may be accessed by others, such as creating passwords to use the computer, keeping their email and chat IDs and passwords secret, and maintaining security of their wireless internet access points. The consultant and client will also choose a password in the first session to be exchanged at the beginning of all subsequent distance sessions in order to verify the identity of the client. Please discuss any additional concerns with your consultant early in your first session so as to develop strategies to limit risk.
E. Alternatives: Online consultation may not be appropriate for many types of clients including those who have numerous concerns over the risks of internet-based services, clients with active suicidal or homicidal thoughts, and clients who are experiencing active manic/psychotic symptoms. An alternative to receiving gender care consultation services online would be receiving services in person. Mere Abrams, MSW can and will assist clients who would like to explore face-to-face options in their area. Please feel free to request a referral at any time you think a different type of consultative relationship would be more practical or beneficial for you.
F. Proxies: The consultant requires this consent form to be completed by the legal guardian of any client seeking services who is under the age of 18. The name and contact information of the legal guardian will be kept as part of the client’s record. Currently Mere Abrams, MSW is only seeing clients 12 years and older.
G. Confidentiality of the client: Maintaining client confidentiality is extremely important to the consultant and the consultant will take extraordinary care and consideration to prevent unnecessary disclosure. Information about the client will only be released with their express and written permission with the exceptions of the following cases: 1) If the consultant believes that someone is seriously considering and likely to attempt suicide; 2) if the consultant believes that someone intends to assault another person; 3) if a consultant suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult; 4) if a consultant believes that someone’s mental condition leaves the person gravely disabled.
H. Records: The consultant will maintain records of online consultation services. These records can include reference notes, copies of transcripts of chat and internet communication and session summaries. These records are confidential and will be maintained as required by applicable legal and ethical standards according to the National Association of Social Workers. The client will be asked in advance for permission before any audio or video recording would occur on the consultant's end. Texts and emails will be deleted once they are documented. Phone call records are automatically stored by the phone provider.
I. Procedures: The consultant might not immediately receive an online communication or might experience a local backup affecting internet connectivity. If the client is in a state of crisis or emergency call 911 or the consultant recommends contacting a crisis line or an agency local to the client. Clients may utilize the following crisis hotlines: 1-800-SUICIDE or 1- 800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY).
J. Payments: All payments will be processed through Square. Clients understand payment of fees is expected at the time of service. Clients agree to pay for each service at the time it is rendered. Clients are responsible for all charges incurred, regardless of insurance status. Clients are required to notify Mere Abrams, MSW at least 48 hours in advance, if I am unable to keep my appointment. If appointments are cancelled at least 48 hours in advance, Mere Abrams, MSW will issue a full refund via Square.
K. Disconnection of Services: If there is ever a disruption of services on the internet, the client will need to call Mere Abrams, MSW to discuss how to proceed with the session. Mere Abrams, MSW can be reached at 510-896-0488. If the client does not call back within 5 minutes, then Mere Abrams, MSW will try and contact them.
I am seeking services from Mere Abrams, MSW. The type and extent of services I receive will be determined following an initial consultation with Mere and me. I will work with Mere to develop a plan designed to assist me in attaining my goals. I understand that this is a collaborative effort between Mere and me.
I understand that I have the freedom to choose to engage in online by distance-consultation, case management, mentoring, education, advocacy and clinical social work services. I understand that there are risks to online services, such as failure in technology or breaches of confidentiality.
By checking the box on the bottom of this consent I agree to abide by its content. I am aware that I have the freedom of choice of providers and I choose Mere Abrams, MSW to provide me with services.