On behalf of myself or on behalf of my child, I hereby consent to teletherapy with the above-selected practitioner. I understand that "teletherapy" is the delivery of psychological services via an interactive electronic system. This can include consultation, treatment, transfer of medical data, emails, telephone conversations and/or education using interactive audio, video, or data communications. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine. As always, your insurance carrier will have access to your medical records for quality review/audit. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.