Before referring a youth for telehealth services, please confirm the following:

Telehealth is not appropriate if the youth is experiencing:

☐ Active safety concerns
☐ Crisis situations
☐ Significant emotional distress
☐ Acute trauma requiring in-person support

Youth Contact and Intake

☐ The youth will complete their own intake form
☐ The youth will use their own personal contact information
☐ The youth will not use another person’s email or contact information

Release of Information (ROI)

☐ A Release of Information (ROI) form has been completed if communication with parents, guardians, or school staff as needed
☐ The ROI form is completed through the BYS website
☐ The ROI will be maintained by BYS

Telehealth Environment

☐ The youth referred has access to a private location for telehealth sessions
☐The youth referred will be in a location where they are able to speak freely and privately.
☐ The session space will allow uninterrupted communication

Telehealth sessions should not occur in environments where:

☐ Others can overhear the conversation
☐ The youth can be viewed by others
☐ The youth cannot participate privately

Clinical Process

☐ The youth can dedicate to the first phase of counseling that includes weekly sessions for approximately 4–8 weeks for assessment