HopeWest Montrose Caregiver Connections Caregiver Registration Form Caregiver InformationName* First Last AgeGender Female Male Ethnicity Caucasian Hispanic Asian African-American Other Marital Status Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Email Caregiver for* First Last Relationship to Person* Age of Person* What are some of your concerns?What topics would you like to focus on during Caregivers Connection? Telemental Health Informed Consent Form I,* (Name of Client)hereby consent to participate in telemental health with HopeWest as part of my grief support. I understand that telemental health is the practice of delivering clinical health care services via technology-assisted media or other electronic means between a practitioner and a client who are located in two different locations. I understand the following with respect to telemental health: 1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled. 2) I understand that there are risk and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. 3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law. 4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue ina legal proceeding). 5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required. 6)I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call/text me at (970) 778-9453 to discuss since we may have to re-schedule. 7) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency. Emergency Contact Name* Emergency Contact Phone*Emergency Contact Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Consent* I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all my questions have been answered to my satisfaction.Signature*Signature of client parent/legal guardianCAPTCHAPhoneCommentsThis field is for validation purposes and should be left unchanged.