VIRTUAL REALITY CLINIC – CLIENT SERVICE

(Clinic for the Education, Treatment, and Prevention of Addictions)
VIRTUAL REALITY CLINIC – CLIENT SERVICE AGREEMENT
“EXPECTATIONS”
Client Name: ______________________________ Client ID Number: ______________________
Participation in the CVRC (CETPA Virtual Reality Clinic) Program is voluntary and it is currently determined by
a CETPA Counselor who believes you are a good candidate for the program.
Our CVRC is located in a confidential website that will allow you, our client, to receive counseling through
Online Video Conference Technology – without having to drive to CETPA. The CVRC will also allow you
access additional information that will enhance your treatment experience at CETPA.
The CVRC program is absolutely free and in order to participate in the program, all we need is a commitment
from you for 12 months..
Once you enter this program, there are a few things that we need to make clear:
1) The CVRC program is a commitment that you as a client, agree to participate in for a period of
12 months.
a. As part of your treatment, you will receive 12 weeks of 45-minute weekly treatment sessions
online with a CETPA counselor at no charge. Additionally, you may also receive video
counseling sessions with our Nurse, Psychologist, and/or Psychiatrist.
b. Before the end of your 12th session, you and your counselor will determine if more
sessions are needed or you are ready for discharge. Even if you are discharged, you
are still expected to fulfill your commitment to the full 12 months. You will be asked to
respond to questions at the end of the 3rd, 6th, and 12th month so that CETPA can
record your progress and we can fulfill the obligations of the grant that allowed you to
receive this free service. You will receive a gift card for your 6th month and 12th month
interview online.
i. If Substance Abuse: You will be asked to complete the CETPA BioPsychosocial assessment to assist with identifying reasons for behavior
change, realizing motivation for change, and identifying long-term negative
consequences of use. To be discharged at the 12th week, you need to be
alcohol and drug free during the 30 days prior to discharge; and it is also
important that you remain abstinent of drugs and alcohol for the assessment at
the 3rd, 6th, and 12th months post admission as measured by the GPRA
(Government Performance and Results Act) and self-report.
ii. If Mental Health: You will be asked to complete the CETPA Bio-Psychosocial
assessment to assist with identifying pleasurable non-using behaviors, longterm positive consequences of pro-social behavior, and increase pro-social
activity. To be discharged at the 12th week, you should exhibit decreased
mental health symptoms at discharge; and, you should continue to have fewer
mental health symptoms at the 3rd, 6th, and 12th months past admission as
measured by the GPRA and LOCUS.
© 2012 CETPA, Inc. All Rights Reserved. Confidential Information. |
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iii. All: To be discharged at the 12th week of the CVRC program, you should be
enrolled in school, vocational training or gain and/or maintain employment; and,
you need to continue to be employed or in school at the 3rd, 6th, and 12th months
post admission as measured by the GPRA and LOCUS.
iv. All: To be discharged at the 12th week of the CVRC program, you should not be
engaging in “new” criminal activity; and, you will abstain from engaging in “new”
criminal activity at the 3rd, 6th, and 12th month post admission as measured by
the GPRA and LOCUS.
v. All: To be discharged at the 12th week of the CVRC program, you will have to
show improved family relationships; and, maintain these improvements at the
3rd, 6th, and 12th month post admission as measured by the GPRA and LOCUS.
vi. All: To be discharged at the 12th week of the CVRC program, you will have to show
“improved quality of life indicators” and, maintain these improvements at the 3rd, 6th, and
12th months post admission as measured by the GPRA and LOCUS.
2) As the Client, you…
a. …agree to inform CETPA if you change your phone number or address during these
twelve months of the CVRC program.
b. …agree to inform CETPA if any part of the technology used for your conference is
down or not working ONE DAY prior to your meeting.
c. …agree to participate in all assessment by CETPA staff, as required by the CVRC
program, to determine care needs.
d. …agree to provide the name and telephone number(s) of your physician(s) and any
other of my pertinent health care providers.
e. ...agree to provide the name and phone number of at least two other people that know
you very well. (family preferable)
f. …will provide access to all medical records relevant to determining your care and
service needs. (if requested)
g. …have the right to ensure that all reasonable requests made by CETPA, with respect
to the confidentiality of the program in your home environment are met.…agree to
follow the plan of care as developed by CETPA, as requested by the CVRC program.
3) Other:
a. While a client is receiving care in this program, staff may collect personal and current
information from the client, under the authority of the Continuing Care Act.
b. CETPA staff and the CVRC program will follow all procedures to ensure confidentiality of the
client’s personal information. Staff shares with other health care providers only relevant
information necessary for the client’s ongoing care and services, and/or in accordance with the
Freedom of Information and Protection of Privacy Act.
Once a member of the CETPA Virtual Reality Clinic…
© 2012 CETPA, Inc. All Rights Reserved. Confidential Information. |
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You can expect that client information from the clinic-side will be treated in the most confidential manner
possible.
1) You can expect to be treated in a respectful manner.
2) You must secure a confidential environment in your residence where others cannot listen to what
you and your counselor are speaking about. This is crucial in order to maintain HIPAA requirements
of confidentiality. This is for the protection of your rights as a client and participant of the CVRC
program.
3) CETPA expects you to be punctual for your session. Your counselor will be waiting for you as you
sign in.
a. The sign in process, to be as confidential as possible, will be:
i. Go to www.cetpa.org
ii. Click on “CETPA Virtual Reality Clinic”
iii. To go to the video-conferencing area, click on “Staff / Empleados”
iv. CETPA will ask for a User Name (This will be provided to you.)
v. CETPA will ask for a Password (This will be provided to you.)
vi. When you enter “Staff / Empleados,” the program GoToMeeting will ask you for a 9-digit
combination (This will be provided to you.)
vii. The GoToMeeting program will ask you for the meeting password (This will be provided
to you.)
viii. After that, the GoToMeeting program will ask for your name (You will enter your client ID
which will be provided for you)
ix. The GoToMeeting program will also ask you for an e-mail ID, enter [email protected].
x. The system may download “Java” or “Citrix” (This is ok.)
xi. The GoToMeeting box will appear on your screen.
xii. Make sure you click on “Mic & Speakers,” so that the counselor can hear you and be
able to talk to you.
xiii. Make sure you click on “Share my webcam,” so that the counselor can see you. This is
a requirement.
As you see we have many areas of security and passwords because the confidentiality of your records is our
main priority
I _______________________ understand that I need to meet the expectations detailed in this document.
I _______________________ hereby request services from CETPA and the CVRC Program. All of the
information that I provide is correct to the best of my knowledge.
SIGNATURE: When signing this agreement, I fully understand that it will be in effect until 12 months (1 year)
after the day it begins. The actual start date (for this program and this grant) will be the day of your first online
meeting with your counselor.
Client ______________________________________________ Date _________________________
CVRC Program Director _______________________________ Date _________________________
If you have any questions about this agreement, please contact
The CVRC Program Director at (770) 662-0249 x 113
© 2012 CETPA, Inc. All Rights Reserved. Confidential Information. |
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(Clinic for the Education, Treatment, and Prevention of Addictions)
“CONTACT INFORMATION”
Client Name: _________________________ Client ID Number: _______________________
Contact # 1:
Name: ________________________________ Telephone: _______________________________
Relationship: ___________________________ Other Phone: _____________________________
Contact # 2:
Name: ________________________________ Telephone: _______________________________
Relationship: ___________________________ Other Phone: _____________________________
Contact # 3:
Name: ________________________________ Telephone: _______________________________
Relationship: ___________________________ Other Phone: _____________________________
Contact # 4:
Name: ________________________________ Telephone: _______________________________
Relationship: ___________________________ Other Phone: _____________________________
Contact # 5:
Name: ________________________________ Telephone: _______________________________
Relationship: ___________________________ Other Phone: _____________________________
Thank you!
© 2012 CETPA, Inc. All Rights Reserved. Confidential Information. |
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Clínica de Educación, Tratamiento y Prevención de Adicciones
Questions to measure the knowledge of technology from our clients.
Preguntas para medir el conocimiento de la tecnología de nuestros clientes.
1. Do you have access to a computer? ( ) Yes ( ) No
¿Tiene acceso usted a una computadora? ( ) Si ( ) No
If yes, does it have speakers? ( ) Yes ( ) No
¿Si sí, tiene parlantes? ( ) Si ( ) No
If yes, does it have a video camera? ( ) Yes ( ) No
¿Si sí, tiene una cámara web? ( ) Si ( ) No
If yes, do you have a microphone? ( ) Yes ( ) No
¿Si sí, tiene usted un micrófono? ( ) Si ( ) No
If yes, do you have access to the Internet? ( ) Yes ( ) No
¿Si sí. tiene acceso al Internet? ( ) Si ( ) No
If yes, what operating system does your computer utilize?
( ) Windows® 7 ( ) Windows® Vista ( ) Windows® XP
( ) Mac OS® ( ) I do not know
¿Si sí, qué sistema operativo utiliza su computadorar?
( ) Windows® 7 ( ) Windows® Vista ( ) Windows® XP
( ) Mac® OS ( ) No sé
2. Do you have an e-mail address? ( ) Yes ( ) No
If yes, what is it? _______________________
¿Tiene una dirección de correo electrónico? ( ) Si (
¿Si sí, cual es? __________________________
) No
3. Do you have a cellular phone? ( ) Yes ( ) No
If yes, what is it? _______________________
¿Tiene una teléfono celular? ( ) Si ( ) No
¿Si sí, cual es? __________________________
4. How comfortable do you feel working with a computer?
( ) Easy ( ) Need Assistant
¿Que tan cómodo se siente usando una computadora?
( ) Cómodo ( ) Necesito Ayuda
5. Are you familiar with sending or receiving emails? ( ) Yes ( ) No
¿Sabe como enviar y/o recibir correos electrónicos? ( ) Si ( ) No
6. Can you upload / download files in the computer? ( ) Yes ( ) No
¿Puede cargar y/o descargar archivos en la computadora? ( ) Si ( ) No
7. Would you feel comfortable speaking to your counselor via a computer? ( ) Yes ( ) No
¿Se sentiría comodo hablando con su consejero(a) através de una computadora? ( ) Si ( ) No
© 2012 CETPA, Inc. All Rights Reserved. Confidential Information. |
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