In Case of an Emergency
* indicates a required field
If you have a mental health emergency, I encourage you not to wait for communication back from me, but do one or more of the following:
North Carolina
Go to your local Emergency Department or call your local 9-1-1 emergency services.
24/7 Behavioral Health Help Line Carolinas Health Care system at 704-444-2400 or 800-418-2065
Mecklenburg County Crisis (CriSyS) Hotline: 704-566-3410
National Suicide Prevention Lifeline Call 1-800-273-8255
Text "CONNECT" to 741741 Free 24/7, Confidential, nationwide, on your phone.
If you are looking for programs or services in your community please dial 2-1-1 or 1-888-892-1162 https://www.nc211.org/
South Carolina
Go to your local Emergency Department or call your local 9-1-1 emergency services.
Catawba Community Mental Health Center (800) 475-1978 http://www.state.sc.us/dmh/cmhc.htm
National Suicide Prevention Lifeline Call 1-800-273-8255
Text "CONNECT" to 741741 Free 24/7, Confidential, nationwide, on your phone.
Emergency procedures specific to Telehealth services
There are additional procedures that we need to have in place specific to Telehealth services. These are for your safety in case of an emergency and are as follows:
You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and Telehealth services are not appropriate.
I require an Emergency Contact Person (ECP) who I may contact on your behalf in a life-threatening emergency only. Please enter this person's name and contact information below.
Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or I determine necessary, the ECP agrees take you to a hospital. Your signature at the end of this document indicates that you understand I will only contact this individual in the extreme circumstances stated above.
Please list your ECP here:
Name: Phone:
You agree to inform me of the address where you are at the beginning of every session. You agree to inform me of the nearest mental health hospital to your primary location that you prefer to go to in the event of a mental health emergency.
Please list this hospital and contact number here:
Hospital: Phone:
You agree to inform me of the nearest police department to your primary location that you prefer to go to in the event of an emergency.
Please list this police department and contact number here:
Police Department: Phone:
INFORMED CONSENT ADDENDUM FOR TELEMENTAL HEALTH
This is to be used in conjunction with, but does not replace, the Informed Consent document that is required of all clients prior to starting therapy services.
What is Telemental Healthcare?
Telemental healthcare includes the practice of diagnosis, treatment, education, goal setting, accountability, referral to resources, problem solving, skills training, and help with decision making through the use of internet-based videoconferencing. Telehealth psychotherapy may include psychological health care delivery, consultation, coaching, and/or counseling. Telehealth psychotherapy will occur primarily through interactive audio, video, and telephone communications.
Risks of Telemental Health
1. Technological failure, such as unclear video, loss of sound, poor connection, or loss of connection.
2. Nonverbal cues are less readily available to both the therapist and the client.
Benefits of Telemental Health
1. Less limitations by geographical location.
2. Reduction of travel to a physical office, which includes decrease in travel time.
3. Participation in therapy from your own home or the environment of your choosing.
The current laws that protect privacy and confidentiality also apply to telemental health. Any exceptions to confidentiality are described in the Informed Consent document.
All existing laws regarding client access to mental health information and copies of mental health records apply.
No permanent video or voice recordings are kept from telemental health sessions. Clients may not record or store videoconference sessions or face-to-face sessions.
Expectations of client during each session
1. Ability to connect to the internet or cellular network.
2. Operational web camera.
3. Dress and environment appropriate to an in-office visit.
4. Only agreed upon participants will be present. The presence of any individuals not approved by both parties and not part of the treatment plan will be cause for termination of the session.
5. The client must disclose the physical address of their location at the start of the session. Unknown locations will be cause for termination of the session.
6. The client shall also provide a phone number where they can be reached in the event of service disruption.
Telemental health may not be the most effective form of treatment for certain individuals or presenting problems. If it is believed the client would benefit from another form of service (e.g. face-to-face sessions) or another provider,
an appropriate referral will be made. The Client has the right to refuse such a
recommendation.
Response to technical difficulties
Should technical difficulties cause session disruption, the therpaist will contact the client via preferred telephone/text contact. If the technical difficulties can be resolved quickly, the session will resume and the client will not experience a shortened session length. If the technical issues cannot be resolved in a timely manner, the session will
be rescheduled for a time when functionality is restored. The client will be contacted by telephone/text to develop a plan for continuation of the session.
Payment
Session costs are outlined in the Informed Consent. Some insurance companies are cover telehealth. Most are covering telehealth on an emergency basis at this time with the Covid19 pandemic.
Consent to Treatment
I, voluntarily, agree to receive Telemental Healthcare assessment, care, treatment, or services and authorize Cycle of Life Counseling, PLLC to provide such care, treatment, or services as are considered necessary and advisable.
I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive through Cycle of Life Counseling, PLLC at any time.
By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.
