Clarification of the Texas Community Supervision Alternatives relationship with the Referring Agency (applicable only if you provided Referring Agency information when enrolling in this course)
It is possible you have been referred to Texas Community Supervision Alternatives, LLC (TCSA) by a government agency or as a requirement mandated by some system or business. (Herein after referred to as the Referring Agency). This referral was made to assist in fulfilling a condition of your relationship with the Referring Agency and made in an effort to help you make changes in order to improve your leave of functioning with others and assist in your being successful. There are a few things that you need to be aware of, so please consider the following:
- I understand that since services are being conducted as a requirement by the Referring Agency.
- I understand that anything and everything that I say, write, do, or convey during this course may be conveyed to the Referring Agency, and may be used against me by the Referring Agency or in a court of law.
- I agree to allow the course facilitator and TCSA to have written, verbal, telephonic and fax contact with the Referring Agency.
- I agree to hold the Course Facilitator and TCSA harmless and from any liabilities or damages which may arise pursuant to the services provided or communication with the Referring Agency.
- I understand that if I want to revoke this release I can do so at any time by submitting a letter to: email@example.com.
You have been given the opportunity to provide a release of information and contact information for a referring agency during your course registration process. If you provided this information, it is recognized that you agree to all of the above.
Information about completion of this Course and Course participation acknowledgments and consents:
- I agree to review all course information, complete all worksheets, and complete quizzes to the best of my ability.
- I understand that my Referring Agency will be informed of my progress throughout the course if I provided consent for this. This consent will no terminate without written notice from me. If I wish to withdraw this consent, I must email my intentions to: firstname.lastname@example.org
- I understand that if I do not review all materials, complete all worksheets, and successfully complete quiz’s, that I will not be acknowledged as having successfully completing my course.
- I understand, and I have been informed that this is not a psychotherapy program, and that the course facilitator’s credentials can be other than a Licensed Professional Counselor and/or a Psychologist.
- I understand that Texas Community Supervision Alternatives, LLC (TCSA) does not offer emergency assistance services and/or crisis counseling. I agree not to attempt to contact TCSA if I am having a crisis and/or an emergency. I will instead contact 911 or other emergency responders.
- I understand that information shared within the course may not be immediately reviewed and that I will not share information through this course as it may pertain to my immediate risk to myself or others.
- I understand that if I do share information about injury and/or abuse to the elderly or minors, TCSA will report the behavior to the appropriate authorities as the information is reviewed by TCSA. This is regardless of consent.
- I understand that photos and videos of individuals within training materials are all actors and are playing roles. The photos and video content in no way represents any information about their true character and behaviors.
- I understand that if identifying information is revealed of program participants who are included in photos and/or videos, they have signed a full release allowing this information to be shared.
- I understand that if I am open and engaged during this course it is likely for me to learn and make heathy changes as a result of using techniques presented within this course. Although, TCSA cannot guarantee healthy changes for all participants.