I understand that all information shared with the therapists at Connections Counseling is confidential and no information will be released without my consent. IfI am a University of Wisconsin Madison student, I understand Connections Counseling and UW-Madison have an established Memorandum of Understanding, allowing for my demographic, assessment and program compliance information to be disclosed between said parties. If I am an Edgewood College student, Iunderstand Connections Counseling and Edgewood College have an established Memorandum of Understanding, allowing for my demographic, assessment and program compliance information to be disclosed between said parties. In all other circumstances, consent to release information is given through writtenauthorization. I further understand there are specific and limited exceptions to this confidentiality: when a specific statutory exception applies or a duty to warnexists.
Connections Counseling, LLC is a certified outpatient drug/alcohol and mental health clinic. The information shared in Choices About Alcohol may elicituncomfortable thoughts and feelings or may lead to the recall of troubling memories. However, Choices About Alcohol may also alleviate problems andsymptoms you present. It is the Choices About Alcohol facilitator’s responsibility to suggest alternative modes of support and will assist in referrals when appropriate and necessary.
Services that are provided through telebehavioral health technologies, use interactive electronic technologies between a clinician and client(s) who are not in the same physical location. By accepting the conditions outlined in the form below you are acknowledging that: you must maintain visual and audio privacy during telehealth sessions including an appropriately private, quiet location without distractions from other people or devices. It is your responsibility to respect and protect the privacy of fellow group members if you participate in group telehealth sessions. Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption. Telehealth may provide access to treatment that would not otherwise be available to me. You will need access to, and familiarity with, the appropriate technology in order to participate in the service provided. The exchange of written information may be indirect, via screen, email or post. During your telebehavioral health consultation, details of my medical history and personal health information may be discussed within the group at your discretion through the use of interactive video, audio or another telecommunications technology. Telehealth services may be discontinued by Connections due to changes in government regulations, insurance, or policy. Upon beginning of each session clinician will request client’s location in case of emergency. The laws and professional standards that apply to in-person behavioral services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.
If you have any questions regarding this consent agreement or about the services offered at Connections Counseling, LLC, you may discuss such with yourChoices About Alcohol facilitator. Also available if requested, is a pamphlet explaining your rights and the grievance procedure available to you. Please ask yourChoices About Alcohol facilitator if you would like a copy. You have the right to withdraw informed consent at any time in writing. Otherwise this consent will be valid for 15 months.
Choices About Alcohol Payment Policy Information
- Students must attend both group sessions as scheduled to successfully complete the program.
- Payment in full ($125) is required to reserve a place in the Choices About Alcohol section and is non- refundable.
- If a student is absent from any group as scheduled, he/she will be required to re-register for Choices About Alcohol and provide $125 in full, again.