Information and Informed Consent for Telemental Health Treatment
Telemental health is live two – way audio and video electronic communications that allows therapists and clients to meet outside of a physical office setting.
Client Understanding
- I understand that telemental health services are completely voluntary and that I can withdraw this consent at any time.
- I understand that none of the telemental health sessions will be recorded or photographed, unless I give explicit permission.
- I agree not to make or allow audio or video recordings of any portion of the sessions without my therapist’s consent.
- I understand that the laws that protect privacy and the confidentiality of client information also apply to telemental health, and that no information obtained in the use of telmental health that identifies me will be disclosed to other entities without my consent.
- I understand that telemental health is performed over a secure communication system that is almost impossible for anyone else to access. I understand that any internet based communication is not 100% guaranteed to be secure.
- I agree that the therapist and practice will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.
- I understand that there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
- I understand that if there is an emergency during a teletherapy session, then my therapist may call emergency services and/or my emergency contact.
- I understand that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and that all office policies and procedures apply to telemental health services.
- I understand that my therapist will advise me about what telemental health platform to use and will establish a video conference session.
Please fill out the form to serve as your electronic signature.