Telebehavioral Health Safety Plan-Kids Instructions: In order to receive telebehavioral health services at our practice, all questions on this form must be answered. If you move, you are responsible for updating your address with our practice and filling out a new form. If you are in a different location from what is listed below, you are responsible for informing your provider at each session. For anyone to be present in your session, your provider must agree that it is clinically appropriate and there must be a signed release on file prior to the session. It is strongly recommended that children are not present for your session. If at any time these policies or your conditions of informed consent are not followed, your session will be ended and you will be charged our private pay rate.1. What address will you be located in during your telehealth session?(Required)If meeting in multiple locations list a second option:2. Do you have a reliable connection to WiFi: (If no, please call our office.)(Required) Yes No 3. What is the best number to reach you if we lose our connection? Phone number: *4. Do you have access to a private location to meet with your provider? Private is defined as the ability to meet via teleconference with video and audio without any other person including children in the room. (If no, please call our office.)(Required) Yes No 5. Please provide the local police department and their non-emergency number below: Police Department &Phone number(Required)6. Do you have any firearms or weapons in the home:(Required) Yes No 7. Is anyone typically present at your location when you are in session with your provider? (If yes please choose other and please list) *(Required) Yes No If Yes (please mention)8. Do you feel safe in your home? (Are there any safety concerns your provider should be aware of including: domestic violence, animals, building infrastructure): (If yes please call our office.)(Required) Yes No 9. We require an emergency contact to call if your provider can not get in touch with you to ensure your safety. Please list their contact information and complete and submit a release form. List the items: Name, Relationship to you, Phone number.(Required)Are they located in your home:(Required) Yes No By signing this form, I agree to, and I understand the following: I agree to allow the Psychiatry Wellness Center to call the above emergency contact. I agree to inform my provider at each session if I am located at a location that is not listed on this form. I understand that I must fill out all sections of this form or I cannot engage in telebehavioral health at this practice. I understand, this form does not guarantee that I may engage in telebehavioral health and that some patients do not meet criteria for telebehavioral health. I also understand that certain sessions per discretion of my provider require a face-to-face meeting in addition to a once-ayear mandatory meeting.Printed Name:(Required) First Last Email(Required) Parent/Legal Guardian Printed Name: Date MM slash DD slash YYYY PATIENT/GUARDIAN SIGNATURE
