Student First Name
Student Last Name
Student Date of Birth
I am on active duty in the armed forces
I am at least 16 years old and reside apart from my parents/guardian and manage my own financial affairs regardless of the source of income
I am thinking about suicide
I have concerns about alcohol and/or drug addiction or dependency
I have been sexually, physically, or emotionally abused
None of these apply.
If any of the above sections have been initialed, then counseling services will be offered without parental/guardian consent.
If none of the above sections apply, we will need parental/guardian consent before beginning DialCare Mental Wellness counseling services. Parental/guardian consent will remain in effect until the minor’s 18th birthday.
Medical Records. You agree to the entry of your medical records into DialCare Mental Wellness’s computer database and understand that reasonable measures have been taken to safeguard your medical information, in accordance with federal HIPAA standards, as amended to date, but no computer or phone system is totally secure.
Prescriptions. You agree that professionals associated with DialCare Group may not prescribe drugs.
Rights. You understand that you have all the following rights with respect to telemedicine consultations:
1. Free Choice. You have the right to withhold or withdraw your consent to a telemedicine consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any benefits to which you would otherwise have been entitled.
2. Access to Information. You have the right to request a copy of all medical information transmitted during a telemedicine consultation, which is described in more detail in the Privacy Notice, and to have such records sent to your primary care physician, including stated costs for obtaining this information which shall not exceed the cost of providing copies.
3. Communications. You understand that, by having your consent to telemedicine consultations, the professional associated with DialCare Mental Wellness may communicate medical information concerning you to physicians and other health care practitioners and others located in other parts of the state/jurisdiction or outside the state/jurisdiction as needed to facilitate the consultation and follow up.
Risks, Consequences, and Benefits. You understand that there are risks from telemedicine consultations, including, but not limited to, the following: 1) loss of records from failure of electronic equipment; 2) power failures with loss of communication; 3) invasion of electronic records by outsiders (hackers); and 4) technological errors that can affect communication and the provision of health care services.
Furthermore, you understand that there are potential consequences of telemedicine consultations, such as reduced in-person contact with health providers. You also understand, however, that there are many potential benefits of telemedicine consultations, including the following: 1) increased availability of health care; 2) availability of real-time data and information; and 3) ease and convenience of receiving health care. Finally, you understand that it is impossible to list every possible risk, consequence, and benefit of telemedicine consultations.
Consent. You agree that you understand the information provided and that you consent to treatment by a professional associated with DialCare Mental Wellness. You agree that as long as this consent is in force (has not been revoked) DialCare Mental Wellness may provide health care services to you via telemedicine without the need for you to grant further consent.
Parent or Guardian (complete if parent/guardian consent is required)
Parent First Name
Parent Last Name
I, (parent/guardian) am the parent or guardian of the minor named above. I understand that under Texas State Law, parents/guardians have access to Counseling/Mental Health Records or could talk with a Counselor whether parental consent is necessary or not. By signing below I acknowledge and agree that:
Minor (must complete whether or not parent/guardian consent is required)
I, (minor) understand that under Texas State Law, parents/guardians have access to Counseling/Mental Health Records if requested or could talk with your Counselor whether parental consent is necessary or not. By signing below I acknowledge and agree that:
I have read and understand the contents of this patient consent, including the limits of confidentiality as stated above.