THINKING FOR A CHANGE - Registration Form

This registration is required so that we can inform your referral source that you have been registered in the class and allow you on to the virtual environment and members area of the site. If you experience an issue submitting this form, try clearing the cache on your device, try submitting via another browser or on another device. If you cannot resolve the issue, please contact us on 832-297-6170 and we will arrange for you to complete the form via an alternative method.

We recommend use of a PC / LAPTOP to submit this information.  In the event that your submission is rejected please continue to press submit until the form has been successfully submitted.

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CONSENT FOR THE RELEASE OF INFORMATION

I hereby authorize: DISCOVER AND RECOVER COUNSELING SERVICES, LLC 2424 Wilcrest Blvd, Houston, TX, 77042 To disclose to and receive from the following specified probation service name/referral source name the following: Confirmation/ verification of registration for the program Participation in program Following of the rules of the program Attendance of the program Successful certificate of completion of the program Unsuccessful discharge of the program Determining eligibility for the program Progress or lack of progress made during the program Progress reports If drugs or alcohol is being used during the program Financial Legal preceding You also agree to us using / releasing any financial, attendance and any other documents required for Discover and Recover to respond to refund request and disputed payments to, but not limited to, WIX and SQUARE.

CONSENT FOR THE ELECTRONIC RELEASE OF INFORMATION

I hereby authorize: DISCOVER AND RECOVER COUNSELING SERVICES, LLC 2424 Wilcrest Blvd, Houston, TX, 77042 To release to me, program and treatment documentation via electronic methods, including but not limited to, email, and text. Discover and Recover Counseling Services, LLC ensures that your data is secure at all times. By signing this you authorize Discover and Recover Counseling Services, LLC, and the counselor to send documentation via electronic methods. You acknowledge that you understand the risks involved and that Discover and Recover Counseling Services, LLC has no control over who might see any emails once they are sent, even though they are sent to the email you via secure HIPAA-compliant methods. My personal information is listed below, which may include information regarding mental, physical, emotional, social, spiritual, legal situations. I understand that this information is voluntary, and I may refuse to sign this authorization. I understand that if the recipient authorized to receive this information is not a covered entity as defined under federal privacy regulations, the disclosed information, except chemical dependency information, may no longer be protected by federal privacy regulations. Description of Information to be disclosed: Confirmation/verification of registration for the program Participation in program Following of the rules of the program Attendance of the program Successful certificate of completion of the program Unsuccessful discharge of the program Determining eligibility for the program Progress or lack of progress made during the program Progress reports If drugs or alcohol is being used during the program Financial Legal preceding You also agree to us using / releasing any financial, attendance and any other documents required for Discover and Recover to respond to refund request and disputed payments to, but not limited to, WIX and SQUARE. At Clients Request I understand this authorization will expire in twelve months. I understand that I may revoke this authorization at any time by notifying Discover and Recover Counseling Services, LLC in writing. I also understand that the written revocation must be signed and dated later than the date on this authorization. The revocations will not affect any actions taken before the receipt of the written revocation. Post dated for one year to date.
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Typical Houston area probation officer's address are:

10585 Westoffice Dr, Houston, TX 77042

9111 Eastex Feeway, Houston, TX 77093

1000 Lee Dr, Baytown, TX 77520

3330 Old Spanish Trail, Houston, TX 77021

451 N Velasco St #300 Angleton TX 77515

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Please sign to acknowledge that you have read the terms, conditions, and rules of the program following, agree to abide by them, and release Discover and Recover Counseling Services, LLC, and its staff from any liability resulting from your participation in this class.

By returning this you agree to all program rules that will be explained to you at the start of your program.  If direct paying for your services, you also acknowledge that you understand and agree to our refund policy that refunds are provided up to 72 hours of the clients start date of their program. Which can be found on our website and will be explained to you at the start of your program.

You also agree that if direct paying by installments,  that you will make your second payment by the data and time specified by the course facilitator.  We reserve the right to block you from attending class if second payment is not made, until such payment is made.

You also confirm that any and all direct  payments for this course have been or will be made using a payment method/card held in your name or by a third-party who is aware and agreed to  it use on your behalf.    Criminal procedures maybe undertaken in the event of suspected fraud either directly or via specified referral source.   Attempts to recover funds for services rendered will also be treated as suspected fraud.

You understand that in order to graduate and receive a certificate that all parts of the program must be completed including attending classes and completing all homework assignments.   Failure to receive a certificate at the end of the program can only be as a result of none-completion of the required course elements.  You accepted that any attempt to libel or slander Discover and Recover's reputation because you failed to receive a certificate due to not completing the required course content, or not following course rules may result in legal action against you.

Welcome to Discover & Recovery's Thinking for a Change program.

We applaud each and every one of you for being here today. We know this journey must be challenging for you. We are glad to have the first step to change with you and are looking forward to working with you. We want to encourage and empower you! This is just a phase in your life, this too shall pass. This class will help you to learn from and not repeat the same mistakes. You will learn knowledge and skills such as Social Skills, Cognitive Self Change, and Problem Solving. You will learn and practice the application of these skills in your daily life. You will be given homework assignments that must be completed and brought back to your next class for processing. The benefits of applying the knowledge and skills you learn in class, are that you will be able to apply them to other areas of your life. Even though probation sent you here, nothing happens by mistake. We employ you to take advantage of what you learn here and make the most of it! If you do, then this may be the last time you will ever have to endure the legal justice system again. Make it count!!!!! We positively challenge you today! How important is it for you, to take back charge over your life and your freedom?

Program Rules and Expectations

These will be provided to you and explained at the start of your program and by signing this deceleration you agree to abide by all the rules, dates for second payments ( if applicable), refund policy, but please by aware of the following:

RULES

1.  PARTICIPATE ACTIVELY

2.  PREPARED AND COMPLETE ALL LESSONS REQUIRED

3.  ATTEND ALL CLASSES ON TIME

4.  BE RESPECTFUL OF OTHERS OPINION

5.  PUT PHONE ON MUTE

6.  MAKE SURE YOUR FACES ARE VISIBLE ON THE SCREEN AT ALL TIMES/STATION YOUR CAMERA SO THAT IT IS STABLE

7.   NO CROSS-TALKING/INTERRUPTING OTHERS

8.  STAY ON TOPIC

9.  CHECK YOUR MIKES FOR ANY INTERFERENCES AND MINIMIZE BACKGROUND NOISE WHEN SHARING

10. DO YOUR BEST TO GET REST THE DAY BEFORE

11. YOU ARE WELCOME TO EAT DURING CLASS AS LONG AS IT DOESN’T INTERFERE WITH CLASS OR YOUR PARTICIPATION. DO NOT SPEAK WITH YOUR MOUTH FULL.

12. CHARGE PHONE/ A DEAD PHONE IS NOT A JUSTIFIABLE REASON TO MISS CLASS. IF YOUR PHONE DIES IT IS NOT AN EXCUSE TO NOT BE IN CLASS, FIND ANOTHER WAY TO BE ON THE PLATFORM).

13. CONTACT THE FACILITATOR IF YOU ARE NOT ABLE TO ATTEND CLASS THAT DAY.

14. THE VIRTUAL PLATFORM LINK/ ID WILL BE SENT BY EMAIL BETWEEN 5.45 PM AND 6 PM.

15. THE GROUP STARTS AT 6 PM. THE GRACE PERIOD IS 15MN. THE CLASSROOM LOCKS AT 6.15 PM.

16. BE RESPECTFUL OF OTHERS

17. IF YOU NEED TO USE THE BATHROOM SEND THE FACILITATOR A TEXT THEN CUT OFF THE CAMERA AND MIKE. PLEASE RETURN PROMPTLY.

18. NO SLEEPING

19. NO LAYING DOWN IN CLASS

20. NO TEXTING

21. NO CUSSING

22. DO NOT WATCH TV WHILE IN CLASS

23. YOUR DEVICE CAMERA AND THE MICROPHONE NEEDS TO WORK AT ALL TIMES (NO EXCEPTIONS).

24. IF DRIVING HOME FROM WORK YOU MUST BE SETTLED IN AND READY FOR GROUP NO LATER THAN 6.15 PM (NOT DRIVING).

25. WEAR CLOTHING THAT DOES NOT REVEAL BREAST CHEEKS OR CHEST OR ANY OTHER PRIVATE BODY PARTS ON THE PLATFORM. DO NOT WEAR ROBES. THIS IS A CLASSROOM ACT AS IF WE ARE IN THE BUILDING.

26. FOCUS ON YOUR PROGRAM, DO NOT TAKE OTHERS’ OPINIONS PERSONALLY

27. WE ONLY DEMONSTRATE POSITIVE AND UPLIFTING FEEDBACK TO OTHERS. NEGATIVE FEEDBACK IS NOT ACCEPTED.

28. DO NOT RECORD, TAKE PICTURES OF THOSE ON THE PLATFORM OR SHARE YOUR LOG-IN INFORMATION WITH ANYONE.

TROUBLESHOOTING

1. IF YOU ARE HAVING ISSUES WITH TECHNOLOGY ON OUR PLATFORM LEAVE THE PLATFORM AND COME BACK IN.

2. IF YOU ARE USING DATA WHEN THE ISSUES OCCUR SWITCH TO WIFI OR VISE VERSA.

3. IF 29 OR 30 DO NOT WORK SWITCH DEVICES OR CALL OR TEXT THE FACILITATOR FOR ASSISTANCE.

4. IF YOU ARE NOT ABLE TO SUBMIT YOUR LESSON ONLINE TAKE SNAPSHOTS OF IT THEN EMAIL IT TO THE FACILITATOR.

NONCOMPLIANCE WITH THESE RULES COULD RESULT IN DISMISSAL FROM THE PLATFORM. YOU WILL RECEIVE 2 WARNINGS. ON THR 3RD WARNING THE INFRACTION TAKES PLACE YOU WILL BE DISMISSED FROM THE PLATFORM WITHOUT WARNING AND WILL NOT RECEIVE CREDIT FOR THAT CLASS. YOU WILL NEED TO MAKE UP THAT CLASS. CLIENTS ARE ALLOWED TO ONLY MISS 1 CLASS PER PHASE AND MUST BE MADE UPON MAKE-UP DAY BEFORE THE CLIENT CAN GRADUATE.

NOTE: THINGS TO KEEP IN MIND FOR YOUR SESSIONS

1.  KEEP YOUR LOG INFORMATION PRIVATE

2.  ENSURE CLASSES ARE NOT DISTURBED BY FAMILY OR FRIENDS

3.  MAKE SURE THERE ARE NO DISTRACTIONS OR NOISES IN THE BACKGROUND OR OTHER PEOPLE ON THE PLATFORM WITH YOU DURING THE CLASS.

You are responsible for your attendance and compliance with the rules. It is not Discover and Recover's job to chase you to attend. We also have no obligation to inform you of your dismissal from our class in the event of continued rule violation.

CLASS ATTENDANCE

You will only be allowed to miss two lessons (2) which must be made up.  If you miss anymore than two, you will be discharged.  You have a 15 minute grace period at the start of the lesson and a 5 minute grace period after the mid-session break.  Attending group after these grace periods will result in you receiving a no-show.    

You are responsible for your attendance and compliance with the rules.   It is not Discover and Recover's job to chase you to attend.  We also have no obligation to inform you of your dismissal from our class in the event of continued rule violation. 

OUR DRESS CODE

Hats turned backward, sagging pants, flip flops, etc. are prohibited for in-office classes or must not be visible for online classes. The client will be asked to correct their attire or will be sent home/asked to leave online classes and given a no-show.

For online sessions, clothing that is revealing but not limited to low-cut blouses, miniskirts, rear cheek revealing shorts, and which are visible on the video, are prohibited.

 

TELE-BEHAVIOR HEALTH

Do not share information about the meeting room used for online classes and/or passwords with anyone. This is to ensure your confidentiality. If this information is compromised you must inform your T4C instructor, Mr. Hinds, immediately so changes can be made for the privacy of those on the call.

 

When you are in class, it is imperative that you are in a secluded place where your video screen cannot be viewed by others. There must not be any other people around you. You should be in a place free from noises or distractions during the class.

 

Failure to comply with these rules could result in consideration for the termination of your services.

Lack of Non-Verbal Cues and Asynchronous Communication

The client should be aware that misunderstandings are possible with telephone, text-based, and virtual based modalities such as email, and real-time internet chat since non-verbal cues are relatively lacking. Even with video chat software, misunderstandings may occur since bandwidth is always limited and images lack detail. Facilitators are observers of human behavior and gather much information from body language, vocal inflection, eye contact, and other non-verbal cues. If you have never engaged in online groups before, have patience with the process and clarify information if you think your facilitator has not understood you well. Be patient if your counselor asks periodically for clarification as well. Since asynchronous communication is “not in real-time,” turnaround time for responding to emails will “lag” a response. Be aware of different time zones as well. The facilitator will make every effort to respond to email requests within a 12–24-hour period. Work with your facilitator to identify local resources if you have concerns about the timeliness of responses.

Privacy and Confidentiality

Maintaining client confidentiality is extremely important. The counselor will take extraordinary care and consideration to prevent unnecessary disclosure. Information about the client will only be released with his or her permission with the following exceptions: If the counselor believes that someone is seriously considering or likely to attempt suicide; 2) if the counselor believes that someone intends to assault another person; 3) If the counselor believes someone is engaging or intends to engage in behavior that will expose another person to a potentially life-threatening communicable disease; 4) if counselor suspects abuse, neglect, or exploitation of a minor or incapacitated adult; 5) if counselor believes someone’s mental condition leaves the person gravely disabled. Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than in person. The client is responsible for understanding the potential risks of confidentiality being breached through non-encrypted email, lack of password protection, or leaving information on a public access computer in a library or internet cafe. Other potential risks of breaching confidentiality could include messages failing to be received if they are sent to the wrong address or if they are just not noticed by the counselor. Confidentiality could be breached in transit by hackers or internet service providers or at either end by others with access to the client’s account or computer. Clients accessing the internet from public locations such as a library, computer lab, or cafe should consider the visibility of their screen to people around them. Position yourself to avoid others seeing your screen. Using cell phones can be risky in that signals are scrambled but rarely encrypted. The counselor has a right to his or her privacy and may restrict the use of any copies or recordings the client makes of their communications. Clients must seek the permission of the counselor before recording any portion of the session and/or posting any portion of said sessions on internet websites such as Facebook or YouTube. The client is responsible for securing their own computer hardware, internet access points, chat software, email, and passwords that are encrypted, secure, and HIPPA compliant when possible. If encryption is not made available to the client, the client should be aware that they are risking unauthorized monitoring of transmissions and/or records of Internet counseling sessions. You agree to work with us online using an encrypted email/chat service determined to be suitable by us. Additionally, 1) If you call us, please be aware that unless we are both on landline phones, the conversation is not confidential. 2) Any computer files referencing our communication are maintained using secure and encrypted measures. 3) We will not respond to personal and clinical concerns via regular email. 4) If you wish to use email as a way to "journal" information between sessions, you understand that we may not have the opportunity to review your journal emails until our next scheduled session. 5) You understand that emails between sessions that contain confidential information will be sent via encryption. We make every effort to keep all information confidential. Likewise, if we are working online together, We ask that you determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors, and friends and whether or not confidentiality from your work or personal computer may be compromised due to such programs as a keylogger. We encourage you to only communicate through a computer that you know is safe i.e. wherein confidentiality can be ensured. Be sure to fully exit all online counseling sessions and emails. If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. We do not place OUR practice as a check-in location on various sites such as Foursquare. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at my office on a weekly basis. Please be aware of this risk if you are intentionally “checking in,” from my office or if you have a passive LBS app enabled on your phone. We may need to consult with other professionals regarding my clients, however, the client’s name or other identifying information is never disclosed. The client’s identity remains completely anonymous, and confidentiality is fully maintained. It is not a regular part of my practice to search for client information online through search engines such as Google or social media sites such as Facebook. Extremely rare exceptions may be made during times of crisis. If we have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, we will fully document it and discuss it with you when we next meet.

Informed Consent for Technology-Assisted Counseling

The purpose of this Informed Consent for Technology-Assisted Education is to inform you, the client, about the process of online services, the facilitator, and the potential risks and benefits of these services. The purpose is to also help safeguard you, the client, and give you information regarding alternatives to online services.

Potential Risks of Receiving Technology-Assisted Counseling & Safeguards

There are various risks related to providing technology-assisted Education services related to the technology used, the distance between facilitator and client, and issues related to timeliness. These risks of concerns for privacy and confidentiality were mentioned in section A. above. Your facilitator has selected an email, chat, and videoconferencing account that is encrypted with a HIPAA-compliant secure platform to allow for the highest possible security and confidentiality of the content of your sessions. Your personal information is encrypted and stored on a secure server. The client is responsible for creating and using additional safeguards when the computer used to access services may be accessed by others such as creating passwords to use the computer, keeping their Email and chat IDs and passwords secret, and maintaining the security of their wireless internet access points (where applicable.) Please discuss any such concerns with your facilitator during your first session so as to develop ways to limit risks. If there is ever a disruption or disconnection of services on the internet, the client will need to contact our office.

Dual Relationships & Social Media

Dual relationships can impair the facilitator and client process, your facilitator’s objectivity, judgment, or effectiveness could be exploitative in nature. We will never acknowledge working with anyone without his/her written permission. In some instances, even with permission, We will preserve the integrity of our working relationship. For this reason, we will not accept any invitations via social networking sites such as Facebook, Twitter, Linked In, or Pinterest, nor will we respond to blogs written by clients or accept comments on my blog from clients. I understand that it is the policy of (DISCOVER AND RECOVER) and their facilitator to NOT “Like’, “Friend” or “Follow” clients on these various social media platforms in order to maintain client confidentiality. (For example, we do not accept or ask for “Friend” requests on Facebook from clients.) I understand too that I may choose to “Like” or “Follow” Discover & Recover social media sites and that there might be certain risks involved such as people associating you with the organization. Please use our social media platforms with discretion. The benefits are that social media allows people to connect. However, we believe that adding clients as friends or contacts on social media sites can compromise your confidentiality and our respective privacy. We feel that it may also blur the boundaries of our relationship.

Alternatives to Technology-Assisted Counseling, Termination & Referrals

Online group education may not be appropriate for many types of clients including those who have numerous concerns over the risks of internet group education, clients with active suicidal/homicidal thoughts, clients who are experiencing active manic/psychotic symptoms, or clients who are minors. An alternative to receiving group education services online would be receiving group education services face to face with the facilitator or adjunct using both modalities or working with another facilitator. The online facilitator can and will assist clients who would like to explore face-to-face options in their local area.

Telephone & Emergency Procedures

If you need to speak with me between sessions to alert me of an emergency, please call us at our office number 346-874-0683. Your call will be returned as soon as possible. Messages are checked daily (but never during the night time.) Messages are checked less frequently on weekends and holidays.

If you have any issues with submitting this form after you uploaded a copy of your ID or the size of the image is > 25mb, then please submit the form without the ID and send the copy of your ID by email to m.hinds@discoverandrecover.net. 

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