Counseling Consent Form

Virtual Race With A View - JFCS Hebrew Academy Orange County is pleased to be able to offer individual or group counseling as one of its support services. This counseling may take place on campus or through a telehealth conference. Your child may be invited to participate. The purpose of the individual or group counseling is to assist students in understanding the feelings of others as well as themselves, to learn problem-solving techniques, to acquire conflict resolution skills, and to increase their self-confidence.

Under the supervision of licensed mental health professionals from Jewish Family and Children’s Service of Greater Long Beach (JFCS), our clinicians will provide counseling services at no cost to the families.

Participation in the program is completely voluntary and contingent upon parent/guardian permission. Issues discussed in therapy are important and are generally legally protected as both confidential and privileged. However, there are exceptions to confidentiality under the following circumstances: 1) Suspected abuse or neglect of a child, elderly person, or disabled person and 2) The clinician’s belief that your child is in danger of harming themself or another person.

If you consent to have your child participate in counseling, if he or she is invited, please fill in the form and return to the front office. In the case of shared legal custody, both parents/legal guardians must sign consent forms. The counselor will notify you if your child is invited to participate.

I consent to engaging in counseling and telehealth with JFCS as part of my child’s counseling. I understand that telehealth includes the practice of healthcare delivery, diagnosis, consultation, treatment, and education using phone, audio-video or data communications.

I understand that I have the following rights with respect to telehealth:

1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.

2) 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 therapy is generally confidential. However, there are both mandatory exceptions to confidentiality, included, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards self, an ascertainable victim or myself.

3) I understand that the dissemination of any personally identifiable images or information from telehealth interaction to researchers or other entities shall not occur without my written consent.

4) I understand that there are risks and consequences from telehealth,included but not limited to:

a) The possibility, despite reasonable efforts on the part of my counselor that the

transmission of my personal information and/or scheduled sessions could be disrupted or distorted by technical difficulties or failures.

b) The transmission of my personal information could be interrupted and/or intercepted by unauthorized persons.

c) Telehealth based services might not be as complete as face to face services. The

potential for misunderstandings exists due to lack of direct visual and auditory cues.

d) Telehealth is not appropriate for crisis situations or individuals with suicidal or

homicidal thoughts.

e) Telehealth is not an appropriate treatment delivery method for individuals with

longstanding and/or serious mental health diagnoses.

5) I have the right to access my clinical information, per California state law and HIPAA guidelines.

6) Telehealth counseling is best when it is done in a private space (no one else in the room) and with no distractions (not while driving or doing dishes, etc.).

I agree that all telehealth services provided by JFCS are understood to be based in the state of California and governed by California law and the California Board of Behavioral Sciences.

Grievance Policy

You have the right to have your complaints heard and resolved in a timely manner. If you have a complaint, please inform your child’s clinician immediately to discuss the situation. If you feel the complaint has not yet been resolved, you may call the JFCS Director of Clinical Services at (562) 427-7916.

Student Information* Last Name First, then list child/ren's names. eg. Doe - John, Jane, Jacob

Check all that apply

There are no legal custody arrangements, and I give permission for my child to participate in counseling via telehealth conference or on-campus services. I have sole legal custody and give permission for my child to participate in counseling via telehealth conference or on-campus services.

I have shared legal custody with the person below, and give my permission for my child to participate in counseling via telehealth conference or on-campus services.

Last Name First Name Relationship

Authorized Signature*

Full Name Phone Number Relationship to child

This is a Secure Form.

Counseling and Telehealth Consent Form

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