Online Request Form for Mass General Brigham Assistance Program Services for Employees
This form is for setting up non-urgent appointments only.
If you are experiencing a life-threatening situation, or if you are experiencing suicidal thoughts, homicidal thoughts or domestic violence, DO NOT complete this form. Please call 911 or go to the nearest emergency room.
We request the following information as a quick and easy way to schedule an appointment with one of our counselors.
* denotes required field
Information regarding the Program Telehealth Appointment
I understand that if I choose to access the Program using a telehealth visit, I am authorizing information about myself to be electronically transmitted in the form of images, voice and data through an interactive electronic connection to and from the Program.
- I understand that a telehealth visit involves the use of electronic (computer) technology and an electronic network. All transmissions are encrypted. The Program does not record these sessions; I agree not to record these sessions either. While these efforts provide strong protections to preserve the security and confidentiality of these transmissions, I understand that no system is 100% secure and I accept the risk that such transmissions may, but will likely not, become viewable by third parties intercepting such transmission.
- I understand that it is my responsibility to ensure that the transmission is not viewed or overheard by third parties with access the device that I am using to receive this transmission.
- I understand the electronic connection may be interrupted during a telehealth visit due to an unavoidable breakdown in technology. If a technology interruption occurs, both parties will try to reconnect. If the connection cannot be made within ten minutes, I understand I can call 866-724-4327 to continue the session via telephone or to reschedule the telehealth appointment.
- I can decide to stop using telehealth visits at any time and elect to be seen in person or be served by other means available from the Program. Also, the Program counselor may decide to stop the telehealth visit if it appears to be detrimental to the service. If circumstances require an urgent or emergency response, Program staff will be prepared to direct me to the appropriate level of care. The Program’s response may include directing me to a local emergency service, hospital or nearby Program office for an in-person assessment to create a plan to maintain safety.
Program Privacy Notice
Federal law requires that all clients be given a copy of the Program Privacy Notice. The Privacy Notice describes in detail how “protected health information” is used and shared with others. The Program has reserved the right to change the Privacy Notice at any time. Obtain a current copy of the Program
Privacy Notice or by contacting the main Program office at 866-724-4327. All reasonable efforts will be made to protect the privacy of Program clients’ protected health information, whether it is maintained on paper or electronically, and regardless of how it is communicated, for example, by email or facsimile.
I understand this Statement, including the confidentiality of the Program and the limitations to confidentiality, and accept it as the terms of my participation in the Program including telehealth visits.
By signing these agreements, (use of email, confidentiality and telehealth) I acknowledge that I have read, understand this statement, including the limitations to confidentiality. I agree to the terms above and I acknowledge that my typed or electronic signature is as legally binding as an original signature.
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