Tele-Bereavement Counseling

Tele-bereavement Counseling

Thank you for your interest in Haven's tele-bereavement counseling. Please fill out the below "Brief Grief Questionnaire" and consent form. Brief Grief Questionnaire Developed by M. Katherine Shear, M.D., AND Sussan Essok, Ph.D. Center for Prolonged Grief, Columbia University

How much trouble are you having accepting the death of your loved one?(Required)

Not at all

Somewhat

A lot

How much does your grief still interfere with your life?(Required)

Not at all

Somewhat

A lot

How much are you bothered by images or thoughts of your loved one at the time of his/her death, or by other thoughts about the death?(Required)

Not at all

Somewhat

A lot

How much are you avoiding places, activities, photographs, conversations, or other reminders associated with your loved one?(Required)

Not at all

Somewhat

A lot

How much do you feel cut off or distant from other people since the death of your loved one, even those you used to be close to?(Required)

Not at all

Somewhat

A lot

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Tele-bereavement Counseling Registration and Informed Consent

Please fill this out before participating in our tele-bereavement services.

Your Name(Required)

First Last

Phone Number(Required)

Email Address(Required)

Date of Birth(Required)

Gender(Required)

Mailing Address (Street, City, State, Zip)(Required)

Name of Deceased(Required)

Your Relationship to the Deceased(Required)

Was your deceased loved one a hospice patient?(Required)

Consent(Required)

Grief Counseling Agreement
I hereby consent to participate in telebereavement counseling with Haven Hospice as part of my bereavement services. I understand that telebereavement counseling is the practice of delivering bereavement services via technology assisted media or other electronic means between a bereavement coordinator/counselor and a griever who are located in two different locations. I understand the following with respect to telebereavement counseling:

1) I understand this is short-term telebereavement grief support counseling (1-6 sessions) and not psychotherapy. If I desire additional counseling, I am responsible to obtain such from a community counselor outside the Haven Hospice provision of services.

2) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

3) I understand that there are risk and consequences associated with telebereavment counseling, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

4) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

5) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telebereavement counseling unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).

6) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telebereavement counseling services are not appropriate and a higher level of care is required.

7) I understand that during a telebereavement session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, the bereavement coordinator/counselor will call me at the above phone number since we may have to re-schedule.

8) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

9) I have acknowledged I have received a copy of the Notice of Privacy Practices.

I acknowledge and understand

Emergency Protocols

We need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. We also need a contact person who I may contact on your behalf in a life-threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.

In case of an emergency, my physical location is:(Required)

My emergency contact person's name, address, phone:(Required)

Crisis Support Acknowledgement

I acknowledge and understand Haven does not provide 24-hour emergency grief support/counseling services. If I need crisis support, I will contact 911 for emergency services, United Way local support at 211, or the National Suicide Hotline at 988 in case of an after-hour emergency or crisis need. I have read the information provided above and discussed it with my bereavement coordinator/counselor. I understand the information contained in this form and all of my questions have been answered to my satisfaction.

Consent(Required)

I acknowledge and understand

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