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GCSU Counseling Services (Georgia College)

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Please initial that you have read this page: ________
GCSU Counseling Services
Tel. # 478-445-5331
Fax: 478-445-2962
Hours: Monday – Friday, 8am to 5pm
INFORMATION, AUTHORIZATION, &
CONSENT TO TELEMENTAL HEALTH
In an effort to provide continuity of services to GC students, Counseling Services is temporarily offering Telemental Health
services during the COVID-19 pandemic. This document is designed to inform you about what you can expect from us
regarding confidentiality, emergencies, and several other details regarding your treatment as it pertains to TeleMental Health.
Both you and your therapist may need to be present in the state of Georgia at the time you are receiving TeleMental Health
services. Please inform your therapist if you are located out of state. TeleMental Health is defined as follows:
“TeleMental Health means the mode of delivering services via technology-assisted media, such as but not limited to, a
telephone, video, internet, a smartphone, tablet, PC desktop system or other electronic means using appropriate
encryption technology for electronic health information. TeleMental Health facilitates client self-management and
support for clients and includes synchronous interactions and asynchronous store and forward transfers.”
(Georgia Code 135-11-.01)
TeleMental Health is a relatively new concept despite the fact that many therapists have been using technology-assisted media
for years. Breaches of confidentiality over the past decade have made it evident that Personal Health Information (PHI) as it
relates to technology needs an extra level of protection. Additionally, there are several other factors that need to be considered
regarding the delivery of TeleMental Health services in order to provide you with the highest level of care. Therefore, our
therapists have completed specialized training in TeleMental Health. We have also developed several policies and protective
measures to assure your PHI remains confidential. These are discussed below.
The Different Forms of Technology-Assisted Media Explained
Telephone via Landline:
It is important for you to know that even landline telephones may not be completely secure and confidential. There is a
possibility that someone could overhear or even intercept your conversations with special technology. Individuals who have
access to your telephone or your telephone bill may be able to determine who you have talked to, who initiated that call, and
how long the conversation lasted.
Cell phones:
In addition to landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone
could overhear or intercept your conversations. Be aware that individuals who have access to your cell phone or your cell
phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each
party was located when that call occurred. However, we realize that most people have and utilize a cell phone.
Email:
Email will be used for notification of technology failures and scheduling purposes only: You may wish to avoid disclosing
information of a personal or sensitive nature in email. If you wish to discuss information of a personal or sensitive nature,
please do so by phone or video conference. If you have an emergency outside of our regular business hours, please follow the
emergency procedures outlined in this document.
Video Conferencing (VC):
Video Conferencing is an option for your therapist to meet with you when it is not feasible to meet face-to-face. We utilize
Cisco Webex. This VC platform is encrypted to the federal standard, HIPAA compatible, and has signed a HIPAA Business
Associate Agreement (BAA). The BAA means that Cisco Webex is willing to attest to HIPAA compliance and assumes
responsibility for keeping your VC interaction secure and confidential. If you and your therapist choose to utilize this
technology, your therapist will email you detailed directions regarding how to log-in securely. We also ask that you please sign
on to the platform at least five minutes prior to your session time to ensure you and your therapist get started promptly. Your
therapist will send an invitation via email to join the telemental health session that you have decided upon beforehand. Your
therapist will make two attempts to contact you at the time of your session and if you do not respond you will be responsible
for contacting the office via telephone or emailing your therapist to re-schedule your appointment. Neither you nor your
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therapist is permitted to record your sessions; however, your therapist will write a progress note that will be placed in your
treatment record, just as they would if you came to a session in person.
We strongly suggest that you only communicate through a computer or device that you know is safe (e.g., has a firewall,
anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.) and is
located in a private setting. Students have access to technology support through SERVE at 478-445-7378 if needed.
Recommendations to Websites or Applications (Apps):
During the course of our treatment, your therapist may recommend that you visit certain websites for pertinent
information or self-help. They may also recommend certain apps that could be of assistance to you and enhance your
treatment. Please be aware that websites and apps may have tracking devices that allow automated software or other entities to
know that you have visited these sites or applications. They may even utilize your information to attempt to sell you other
products. Additionally, anyone who has access to the device you used to visit these sites and/or apps, may be able to see that
you have been to these sites by viewing the history on your device. Therefore, it is your responsibility to decide if you would
like this information as adjunct to your treatment or if you prefer that your therapist does not make these recommendations.
Please let your therapist know by checking (or not checking) the appropriate box at the end of this document.
Your Responsibilities for Confidentiality & TeleMental Health
Please communicate only through devices that you know are secure as described above. It is also your responsibility to
choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-
workers, strangers, and hackers could either overhear your communications or have access to the technology that you are
interacting with. Additionally, you agree not to record any TeleMental Health sessions.
Communication Response Time
I am required to make sure that you are aware that Counseling Services is in the Eastern Time zone. As stated earlier, both
you and your therapist are required to be physically present in the state of Georgia in order to receive TeleMental Health
Services from our center. If you are not in the state of Georgia, please let your therapist know with advanced notice so that
they can consult their appropriate agency and see if they can legally provide services to you. GC Counseling Services is
considered to be an outpatient facility, and we are set up to accommodate individuals who are reasonably safe and resourceful.
We do not maintain 24 hour availability. If at any time this does not feel like sufficient support, please inform your therapist,
and they can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. We will return
phone calls and emails within 24 hours. However, we do not return calls or emails on weekends or holidays as we are still
operating under our usual business hours. If you are having a mental health emergency and need immediate assistance, please
follow the instructions below.
In Case of an Emergency
If you have a mental health emergency, we encourage you not to wait for communication back from your therapist, but do
one or more of the following:
• Call Behavioral Health Link/GCAL: 800-715-4225
• Call or visit River Edge Crisis Service Center: 478-451-2797, 60 Hwy 22 West, Milledgeville
• Call Georgia College Public Safety 478-445-4400
• Call Lifeline at (800) 273-8255 (National Crisis Line)
• Text National Crisis Text Line by texting TALK to 741741; www.crisistextline.org
• Call or visit your local hospital ER. In Milledgeville, the local hospital is Navicent Baldwin Health Emergency
Room: 478-776-4016, 821 N. Cobb St. Milledgeville
• Call 911.
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Emergency Procedures Specific to TeleMental Health Services
There are additional procedures that we need to have in place specific to TeleMental Health 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, we may determine that you need a higher level of care and TeleMental Health
services are not appropriate. We will assist you with referrals in your community if needed.
• We require an Emergency Contact Person (ECP) who we may contact on your behalf in a life-threatening
emergency only. Your signature at the end of this document indicates that you understand we will only contact this
individual in the extreme circumstances stated above.
• You agree to inform your therapist of the address where you are at the beginning of every TeleMental Health
session.
• You agree to inform your therapist of the nearest mental health hospital to your primary location that you prefer
to go to in the event of a mental health emergency (usually located where you will typically be during a TeleMental
Health session).
In Case of Technology Failure
During a TeleMental Health session, you and your therapist could encounter a technological failure. The most reliable
backup plan is to contact one another via telephone or email. Please make sure you have a phone with you, and your therapist
has that phone number. Your therapist’s personal number will not be provided; however, you can contact our office during
regular business hours (M-F 8am to 5pm) and a staff member will contact that therapist for you and have them call you back.
If the staff member is unavailable, please leave a voice mail and they will return your call as soon as they can.
If you and your therapist get disconnected from a video conferencing, end the session and wait for your therapist to initiate
a new session. If you are unable to reconnect within ten minutes, please email your therapist directly or contact the office at
478-445-5331.
If you and your therapist are on a phone session and you get disconnected, please wait for your therapist to call you back.
If you do not receive a call from your therapist within 10 minutes, please call the office at 478-445-5331.
Cancellation Policy
In the event that you are unable to keep a TeleMental Health appointment, you must notify your therapist directly by email
or by calling our office at 478-445-5331 at least 24 hours in advance.
Limitations of TeleMental Health Therapy Services
TeleMental Health services should not be viewed as a complete substitute for therapy conducted in our office, unless there
are extreme circumstances that prevent you from attending therapy in person. It is an alternative form of therapy or adjunct
therapy, and it involves limitations. Primarily, there is a risk of misunderstanding one another when communication lacks
visual or auditory cues. For example, if video quality is lacking for some reason, your therapist might not see a tear in your eye.
Or, if audio quality is lacking, he or she might not hear the crack in your voice that he or she could have easily picked up if you
were in our office.
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 personal interaction.
Please know that we have the utmost respect and positive regard for you and your well-being. We would never do or say
anything intentionally to hurt you in any way, and we strongly encourage you to let your therapist know if something she or he
has done or said upset you. We invite you to keep the communication with your therapist open at all times to reduce any
possible harm.
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Consent to TeleMental Health Services
Please check the TeleMental Health services you are authorizing your therapist to utilize for your treatment or
administrative purposes. You and your therapist will ultimately determine which modes of communication are best for you.
However, you may withdraw your authorization to use any of these services at any time during the course of your treatment
just by notifying us in writing. If you do not see an item discussed previously in this document listed for your authorization
below, this is because it is built-in to our practice, and we will be utilizing that technology unless otherwise negotiated by you.
Phone calls
Email (for scheduling and notification of technology failures only)
Video Conferencing
Recommendations to Websites or Apps
In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this
time. Feel free to ask questions, and please know that we are open to any feelings or thoughts you have about these and other
modalities of communication and treatment.
Emergency Contact Person
Name: __________________________ Relationship:_________________ Phone: _______________________
Your Primary Address
_________________________________________________________________________________________
Closest Hospital
Name:_________________________ Address:______________________Phone:_______________________
Pharmacy
Name:_________________________Address:______________________Phone:________________________
Please print, date, and sign your name below indicating that you have read and understand the contents of this form, you agree
to these policies, and you are authorizing us to utilize the TeleMental Health methods discussed. Please scan or photograph
this form and email it back to your therapist. You may also fax this form to 478-445-2962. Keep in mind that you will be
unable to receive TeleMental Health services until your therapist has received this document.
__________________________________________________ _________________
Client Name (Please Print) Date
__________________________________________________
Client Signature
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Completed 20 August 2020

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