By sigining and submitting this document, I hereby consent to engage in
virtual coaching with Christian T. Hill, MA. I understand that virtual coaching includes consultation, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. I understand that virtual coaching also involves the communication of my medical/mental information, both orally and visually.
I understand that I have the following rights with respect to virtual coaching:
1. I have the right to withhold or withdraw consent at any time without affecting myright to future care.
2. I understand that the information disclosed by me during the course of my coaching or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality as it relates to immenent harm to self or others.
3. I understand that there are risks and consequences from virtual coaching, including, but not limited to, the possibility, despite reasonable efforts on the part of Mr. Hill, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
4. In addition, I understand that virtual coaching based services and care may not be as complete as face- to-face services. I also understand that if Mr. Hill believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I will be referred to a professional who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of consultation, and that despite my efforts and the efforts of my coach, my condition may not be improve, and in some cases may even get worse.
5. I understand that I may benefit from virtual coaching, but that results cannot be guaranteed or assured.
6. I accept that virtual coaching does not provide emergency services. During our first session, Mr. Hill and I will discuss an emergency response plan. If I am
experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support.
7. I understand that I am responsible for (1) providing the necessary computer,
telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my virtual coaching session.
8. I understand that while email may be used to communicate with Mr. Hill,
confidentiality of emails cannot be guarranteed.
9. I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law.