Consent for Telehealth Peer Support

If we meet by phone, video call, or text instead of in person, this form covers a few extra things you should know.

Telehealth peer support means we may meet by phone call, video conference (such as Google Meet or Zoom), secure messaging, or text. The benefits: access when weather, transportation, illness, or distance would otherwise get in the way. The limits: technology can fail; a video screen cannot replace being in the same room; and if a true emergency happens during a session, we may need to end the call and contact 911 / your emergency contact. I understand Heart of Care will take reasonable steps to protect the privacy of our remote sessions (headphones, private room, non-public networks). I am also responsible for finding a private space on my end and using a device I trust. I understand that no electronic communication is 100% secure, and I accept that risk. I understand a peer specialist cannot deliver crisis intervention through telehealth alone. In a crisis I will call 988 or 911, or go to the nearest emergency department.

About you

Full legal name *

Name you'd like us to use

Date of birth *

Pronouns

Best phone number *

Preferred way to meet

How I'd most like to meet *

Phone callVideo callSecure messaging / textMix — whatever fits the day

If technology fails, we should…

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