New/Annual Visitor Form

Each year, Cancer Support Community Valley/Ventura/Santa Barbara (CSCVVSB) gathers information about every participant to help us better understand who comes to our programs. All personal information will be kept confidential. Since we are a non-profit organization that does not charge for our services, we rely solely on donations to underwrite our programs and we need to collect the following information annually to help us secure funding. The information provided to funders only includes demographic data of all participants with no identifying information. Your answers to these questions will, in no way, affect your ability to access all programs at CSCVVSB at no charge.

STATEMENT OF CONFIDENTIALITY

Our staff and volunteers respect the privacy of our members. Cancer Support Community Valley/Ventura/Santa Barbara (CSCVVSB) adheres to professional, legal, and ethical standards of confidentiality established by professional organizations and state law. Legal and ethical exceptions to confidentiality include: a clear or present danger to harm oneself or another, knowledge of the abuse or neglect of a minor child, elder or dependent/incapacitated adult, or responses to a court subpoena or as otherwise required by law.

We ask that our members respect each other’s privacy and do not disclose the identity of others who participate at CSCVVSB, or what is said in a support group or program. However, we are not able to ensure confidentiality of all members, as we would have no way to enforce it. Please read and sign below regarding our policies for the confidentiality, virtual (online) confidentiality and communication, comfort and safety of our members.

• I understand that the CSCVVSB staff and volunteers will be respectful of my privacy but cannot ensure the confidentiality adherence of other members.
• I understand that the CSCVVSB reserves the right, at its sole discretion, to refuse or discontinue the use of its facilities and its virtual (online) platforms to any person.
• I agree not to share other members’ personal information, such as name, address, email address, phone number, and medical information, to any other third party.
• I understand that the CSCVVSB does not provide medical advice or assistance of any kind.
• I agree not to attend the CSCVVSB programs if I have a communicable illness, as some of our members have compromised immune systems.
• I understand that the CSCVVSB is a fragrance-free space, as some members may be very sensitive to smell.

In consideration of my acceptance as a member of Cancer Support Community Valley/Ventura/Santa Barbara (CSCVVSB), and its partners (including, but not limited to: Saint John’s Dignity Health, Ventura County Medical Center) and the use of the facilities and services provided without charge, I agree that I will not take any legal action against the CSCVVSB, its program partners, its officers, agents, employees, interns, or any other participant or support person at CSCVVSB, based in any way on what is said or done by such officers, agents, employees and participants at CSCVVSB in a good faith effort to provide those services and facilities.

HEALTHY LIFESTYLE CLASSES ATTENDANCE GUIDELINES

I fully understand that CSCVVSB and program partners recommend that anyone participating in any exercise/relaxation/social program, both in-person and virtual (online), check with their healthcare provider prior to participation to ensure that they are medically able to do so. Participation in any such program, both in-person and virtual (online), could result in injury or illness.

CONFIDENTIALITY

There is great respect for confidentiality at Cancer Support Community Valley/Ventura/Santa Barbara (CSCVVSB). Very little that goes on in the groups becomes public knowledge – not because of a promise or guarantee by CSCVVSB but because of the innate integrity of the participants, the awareness of the harm that gossip can do, and an implied, unspoken, well-accepted agreement among the participants. We recognize that there is a stress-related factor when secrets are held onto. We encourage you to let go of that stress. However, if it is very important to you that a specific fact not be revealed, it is best not to speak about it in group. There is no guarantee of confidentiality made by CSCVVSB or anyone associated with CSCVVSB.

STATEMENT OF POLICY

I wish to join a Support Group at CSCVVSB. I have or will attend an orientation and I have read the statement on confidentiality at CSCVVSB. Additionally, I AM AWARE AND UNDERSTAND:

• That CSCVVSB adheres to professional, legal, and ethical standards of confidentiality established by professional organizations and state law. Legal and ethical exceptions to confidentiality include: a clear or present danger to harm oneself or another, knowledge of the abuse or neglect of a minor child, elder or dependent/incapacitated adult, or responses to a court subpoena or as otherwise required by law.
• That CSCVVSB reserves the right, at its sole discretion, to refuse or discontinue the privilege of use of its facilities or services to any person.
• That CSCVVSB does not provide medical advice or assistance of any kind.
• That I do not have any communicable diseases such as hepatitis or tuberculosis, and if I have a cold or flu, I will not attend a group meeting.
• That I will not share other group members’ contact information with anyone outside the group.
• That sometimes it is difficult to understand how groups can be helpful, and therefore, I will try to attend at least three (3) meetings before deciding if a group is not for me (if that is the case).
• That CSCVVSB’s Support Groups are particularly beneficial during times of transition—at diagnosis, during treatment, as treatment ends and “life after treatment” begins, recurrence, etc, and are not intended to be a place where people land indefinitely.
• That CSCVVSB’s Weekly Support Groups are to provide emotional support and hope for people who are actively involved in the day-to-day fight for recovery. I, therefore, agree that if and when I have been free of the physical symptoms of cancer and its treatment for a period of eighteen (18) months, I will notify the facilitator of my group and will voluntarily leave the group.
• That, for the same reason, I, as a caregiver (a support person), agree that if and when my loved one with cancer has been free of the physical symptoms of cancer and its treatment for a period of eighteen (18) months, I will notify the facilitator of my Caregivers’ (Family & Friends) Group and will voluntarily leave the group.

TELEMENTAL HEALTH CONSENT
This Section indicates your consent to participate in distance-oriented support group sessions, otherwise known as telemental health, which take place over a HIPAA compliant telemental health platform, Zoom. Further, this document is designed to inform you about what you can expect regarding confidentiality, emergencies, and several other details during group participation as it pertains to telemental health at CSCVVSB. Telemental health is the mode of delivering group counseling services via technology-assisted media, such as telephone (landline and mobile devices), video conferencing, internet, tablet, PC desktop system or other electronic means using appropriate encryption technology for electronic health information.

Limitations of Telemental Health: Telehealth can be utilized in circumstances that prevent you from CSCVVSB’s in-person programs and services. Please be aware that there is a risk of misunderstanding group members when communication lacks visual or auditory cues. There may also be a disruption to the service (e.g., phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of group interaction. By Signing This Consent, You Understand and Agree to the Following:

• First and foremost, protecting my and other support group members privacy is important. Therefore,
  • I will find a private and protected space for all group sessions.
  • During group, no one else will be present in the room.
  • If a protected and private space is not available, I will minimize the presence of other people or animals in the space, and ensure to use a headset or ear buds during the group sessions to protect other members’ privacy.
  • I will not share the online support group link with anyone in any case.
• To avoid distractions and show respect for other support group members,
  • I will log in on time.
  • I will solely focus on the group and not engage in any other activities during the group sessions.
  • I will not accept other phone calls, texts, and emails or engage in web surfing during our sessions.
  • Prior to joining an online group, I will obtain a reliable Internet connection and necessary devices and use them all the time.
• I know how to utilize video conferencing technology and/or agreed upon technology-assisted devices.
• I understand the limitations of telemental health and it is not a complete substitute to the programs offered at the Cancer Support Community Valley/Ventura/Santa Barbara.
• I understand that a telemental health support group has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
• I understand that my support group facilitator can discontinue the group if it is felt that the videoconferencing connections are not adequate.

In Case of Technology Failure:
During a telemental health support group, there could be a loss of phone or Internet connection. If you get disconnected from a video conferencing group, end and restart the session. If you are unable to reconnect within ten minutes, please email the facilitator for instructions.

In Case of an Emergency:
If you have a mental health emergency, you are encouraged not to wait for communication back from your facilitator, but to do one or more of the following:

• Call Lifeline at (800) 273-8255 (National Crisis Line)
• Call 911
• Go to the nearest emergency room

You understand that if you are having suicidal or homicidal thoughts, experiencing symptoms of psychosis, or in a crisis that we cannot solve remotely, your facilitator may determine that you need a higher level of care and telehealth services are not appropriate. CSCVVSB requires an Emergency Contact Person who your facilitator or other staff members may contact on your behalf in a life-threatening emergency.

By electronically signing and submitting this document, I agree to all CSCVVSB policies above, and I authorize CSCVVSB to utilize the telemental health methods discussed. I have read the above statements and agree to abide by them.

I also agree to release, waive, discharge and hold harmless CSCVVSB and its program partners, affiliates, employees, interns, officers, agents, independent contractors, volunteers and donors from any and all claims, actions, demands, liabilities, expenses (including attorneys’ fees) and losses arising from bodily injury or illness, including, but not limited to, wrongful death, loss of services, loss of consortium, and all other damages that may arise out of participation in the exercise program.

I HAVE READ AND UNDERSTAND THE WAIVER AND RELEASE AGREEMENT