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Autistic Parent Support Group Consent

Introduction: I, Danielle Aubin, LCSW, am organizing a support group specifically designed for autistic parents. Before you decide to participate, it is important for you to understand the purpose of this group and what your participation entails. Please read this consent form carefully and feel free to ask any questions you may have.

Location: In order to participate in this group, you must reside in a state that Danielle is licensed in (CA, MN, FL or AR) at the time of the group session. 

Purpose: The purpose of this support group is to provide a safe and supportive environment for autistic parents to connect, share experiences, and access resources. The group aims to foster mutual understanding, validation, and empowerment among participants.

Group Facilitator: I, Danielle Aubin, LCSW, will facilitate the support group sessions. As a licensed clinical social worker with experience in supporting autistic individuals and families, I am committed to creating a respectful and inclusive space for all participants.

Confidentiality: Confidentiality is of utmost importance in this support group. What is shared in the group, including personal experiences and information about participants, should be kept confidential by all members. It is crucial to respect each other's privacy and refrain from sharing outside of the group. As a therapist, I am there are limitations of such client held privilege of confidentiality exist and are itemized below:

If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items (3) and (4).
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
 

Participation: Your participation in this support group is voluntary. You have the right to withdraw from the group at any time without penalty or consequence. Additionally, please remember that you are not obligated to share anything you are uncomfortable with. Your level of participation is entirely up to you.

Expectations: As a participant in this support group, it is expected that you will:

  • Respect the experiences and perspectives of other group members.

  • Refrain from judgmental or discriminatory behavior.

  • Maintain confidentiality regarding what is shared in the group.

*You are welcome to come and go from the meeting as needed, have your camera on or off, speak and/or engage or simply participate via observation only*

Benefits and Risks: Participating in a support group can offer various benefits, including emotional support, validation, and access to helpful resources. However, it is essential to acknowledge that discussing personal experiences may evoke strong emotions. While the group aims to provide a supportive environment, it cannot guarantee that all participants will have the same experience.

 

SERVICES PROVIDED VIA TELEHEALTH

In California/Minnesota/Arkansas/Florida, “Telehealth” is defined as a method to deliver health care services using information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient and provider are at two different sites.

This form of service usually consists of live videoconferencing through a personal computer with a webcam.

I understand that I have the following rights with respect to telemental health:

1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any benefits to which I would otherwise be entitled.

2) The laws that protect the confidentiality of my medical information also apply to telemental health.

3) I understand that the same laws that give me the right to access my medical information and copies of medical records in accordance with California/Minnesota/Arkansas/Florida law also apply to telemental health.

4) I understand that the dissemination of any personally identifiable images or information from the telemental health interaction to researchers or other entities shall not occur without my written consent.

I understand the following potential risks, consequences, and limitations of telemental health:

• Telemental health (TMH) should not be viewed as a substitute for face-to-face counseling or medication by a physician. It is an alternative form of counseling with certain limitations.

• TMH is relatively new, and therefore lacks research indicating that it is an effective means of receiving therapy.

• TMH may not be appropriate if you are having a crisis, acute psychosis, or suicidal or homicidal thoughts.

• TMH may lack visual and/or audio cues, which may increase the likelihood of misunderstanding each other.

• TMH may have disruptions or delays in the service and quality of the technology used.

• In rare cases, security protocols could fail and your confidential information could be accessed by unauthorized persons.

Emergency Contact

If you are ever experiencing an emergency, including a mental health crisis, that is life or death, please call 911, Lifeline 1-800-273-8255, or go to your nearest emergency room. If you just need to talk with a counselor, please call 760-750-4915 and when prompted enter “9” to be connected with a counselor from a contracted agency.

So that Danielle Aubin, LCSW is able to get you help in the case of an emergency and for your safety, the following are important and necessary. By signing this agreement form you are acknowledging that you understand and agree to the following:

• You must inform Danielle Aubin, LCSW of the location in which you will consistently be during sessions, and inform your them if this location changes.

• You must identify on your informed consent form a person who can be contacted in the event that Danielle Aubin, LCSW believes your safety is at risk.

• Danielle Aubin, LCSW may need to verify that your emergency contact person is able and willing to go to your location in the event of an emergency, and/or call 911 or transport you to a hospital if Danielle Aubin, LCSW deems necessary. In addition, Danielle Aubin, LCSW may require that you create a safe environment at your location during the entire time that you are in treatment. This may mean disposing of all firearms and excess medication from your location.

When receiving telemental health, it is also required that you:

• Only engage in sessions when you are physically in California/Minnesota/Arkansas/Florida. Your provider will confirm this each session.

• Engage in sessions only from a private location where you will not be overheard or interrupted.

• Use your own computer or device, or one owned by CSUSM that is not publicly accessible.

• Ensure that the computer or device you use has updated operating and anti-virus software.

• Do not record any sessions, nor will Danielle Aubin, LCSW record your sessions without your written consent.

I have read and understand the information provided above. I have discussed it with Danielle Aubin, LCSW and all of my questions have been answered to my satisfaction

Note on privacy: If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Acknowledgment: By signing below, you acknowledge that you have read and understood the information provided in this consent form. You agree to participate voluntarily in the support group session facilitated by Danielle Aubin, LCSW.

Danielle Aubin, LCSW's license information: CA Lic# 87299, MN Lic#31754, AR Lic#12748-C, FL Reg#TPSW2631

You're all set. Thank you!

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