Telehealth Consent Form – Healing Tree

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Healing Tree - Informed Consent Agreement

Welcome to the Dempsey Centers for Quality Cancer Care, our mission is to provide quality of life services to individuals and families impacted by cancer. If you are reading this form, you or a minor family member has chosen to participate in our Healing Tree Program. The Healing Tree program provides an array of professionally-led services, centered on educating and supporting children and families around the impact of cancer or cancer-related loss.

Programs and Services

HT services may include, but are not limited to: Healing Tree Introductions, individual counseling, family counseling, parent support and education, adventure based therapy, support groups, youth and family focused specialty programs, health and wellness programs and complementary therapy services offered to youth clients.

The Healing Tree Services constitute confidential, personal health information (“PHI”) regarding your child. You will be provided a separate Notice of Privacy Practices regarding the steps Dempsey Centers takes to protect the confidentiality of the PHI. In addition, please know that as a parent/legal guardian, you have the right to know about the confidential communications we have with your child. Confidential communications may be shared with you at your request, unless a licensed clinician determines, based upon the particular circumstances, that disclosure is not in the best interest of your child. Information may be shared verbally, through copies of progress notes, or by written summary, at the option of the provider.

As separately detailed in the Notice of Privacy Practices, there are situations when confidential PHI that includes counseling information may be disclosed to third parties by the Dempsey Centers, without a signed authorization by you. This includes, by way of example, when:

1. Necessary to help avert an imminent threat of serious harm to a client or others;
2. A report is mandated by law, if there is a reasonable suspicion of child abuse or abuse of an elder or incapacitated person;;
3. 3. Disclosure is required by a valid court order;

With respect to the services for your child, by signing below, you acknowledge the following:

• I understand that
Name of Child:(Required)
may be exposed to age-appropriate medical terminology, including the words, “cancer, “chemo”, and “radiation.” I understand that my child will be learning social and emotional concepts and coping skills related to such stress, anger, sadness, isolation and grief.

• I understand that though the Healing Tree program at the Dempsey Center provides professional counseling services, its purpose is centered on educating and supporting children and families around the impact of cancer or cancer-related loss.

• I understand the importance of notifying staff of any additional, significant changes in my child’s life. I understand that staff may request a family meeting to discuss my child’s needs, including whether the program is an appropriate for my child.

• I understand that for a minor child below the age of 16, at least one parent (or a substitute designated in writing) is required to remain available in the building during any activity sessions, unless otherwise specified.

• If my child has cancer, I understand that I should consult my child’s primary care provider or other attending physician, before having him/her participate in any physical activities and to follow his/her physician’s, or other healthcare professional’s advice with respect to such activities.

• I understand that the services offered through Healing Tree are not a substitute for medical care and that these services are only intended as ancillary support services to medical care.

• I understand that any recreational or physical activity involves some risk of injury, whether apparent or not, and by participating in any such activity I assume all risks for my child, known or unknown, whether foreseeable or not..

Email/Social Media Communication The use of e-mail or other social media for communicating about personal health information with Dempsey Centers staff is discouraged. However, if you do choose to use an electronic medium for communicating, Dempsey Centers may decline to share personal health information electronically, due to concerns regarding security and confidentiality.

Please note that our counselors do obtain case consultation from time to time on an as-needed basis as reasonably necessary to support and enhance the delivery of the counseling services. Any such consultations would be de-identified to protect confidentiality to the greatest extent possible.

Emergency Procedure I understand that the Dempsey Center is not equipped to address medical or mental health emergencies. In the event of a life-threatening or other emergency, I should call 911. In the event of a mental health crisis, I am aware I can call Maine State Crisis Hotline at 1-888-568-1112.

Inactive RecordsClient records will be retained for seven years. The time period begins from the date of the last visit or for minors, from the date they reach 18. Should there be any further direct client contacts involving health care services, the counting period will begin again at the date of new service.

My signature on this Healing Tree Informed Consent Agreement indicates that I:

• Have reviewed, understand, and consent to the policies and information above, and

• Consent for my child to participate in Healing Tree services and programs at the Dempsey Center

Child's Name(Required)
Parent/Guardian Name:(Required)
I understand that my typed name above will carry the same effect as my written signature(Required)
Parent/Guardian Name:
I understand that my typed name above will carry the same effect as my written signature