1. I understand that I am giving my consent to engage in a video therapy sessions with my provider.
2. I understand that the telehealth appointments will not be the same as an in-person session with a provider due to the fact that we will not be together in the same room. I also understand that, in order to have the best results for this session, I should be in a quiet place with limited interruptions when I start the session.
3. I understand the potential risks to the use of technology, which can include interruptions, unauthorized access and technical difficulties. I understand that my provider or I can discontinue the video therapy session if it is felt that the video conferencing connections are not adequate for the situation.
4. My provider agrees to inform me and obtain my consent if another person is present during the consultation, for any reason. I agree to inform my provider if there is another person present during the session or if I want to record our session.
5. I understand that there are alternatives to a video therapy session available, including in-person sessions or phone sessions.
6. I understand that I can direct questions about this video therapy session at any time to my provider.
7. I understand that this consent will last for the duration of the relationship with my provider, including any additional video therapy sessions I may have; I can withdraw my consent for video therapy sessions at any time.
8. I understand that same confidentiality protections, limits to confidentiality, and rules around my records apply to a video therapy session as they would to an in-person session.
9. I agree to work with my provider to come up with a safety plan, including identifying one or two emergency contacts, in the event of a crisis situation during our sessions.
We also need to create a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems
10. I understand that my provider may decide to terminate video therapy services, if they deem it inappropriate for me to continue therapy through video sessions. My provider will work with you to discuss other options for in-person care.
By signing this form, I certify:
● That I have read or had this form read and/or had this form explained to me.
● That I fully understand its contents including the risks and benefits of the process for video therapy.
● That I have been given opportunity to ask questions and that any questions have been answered to my satisfaction.
● That I agree to participation in a video therapy session(s) with my therapist at CORE Connection Counseling.