I, as the parent or legal representative for the above named client or as the client listed above, agree to receive individual therapy, family therapy, and/or an individual diagnostic evaluation, as a telehealth service. I understand that the health care practitioner employed by Behaven Kids is located at either Behaven Kids Omaha, 8922 Cuming Street, Omaha, NE 68114, Behaven Kids Lincoln, 1145 High Street, Lincoln, NE 68502, or Behaven Kids Elkhorn, 20275 Honeysuckle Dr. Elkhorn NE 68022. A telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment. This consent is valid for one year for follow-up telehealth services with the practitioner.

I also understand that:

• I can decline the telehealth service at any time without affecting my right to future care or treatment, and any program benefits to which I would otherwise be entitled cannot be taken away.
• I may have to travel to see a health care practitioner in-person if I decline the telehealth service.
• If I decline the telehealth services, other options/alternatives may be available for me, including in-person services.
• The same confidentiality protections that apply to my other medical care also apply to the telehealth service.
• I will have access to all medical information resulting from the telehealth service as provided by law.
• The information from the telehealth services (images that can be identified as mine or other medical information from the telehealth service) cannot be released to researchers or anyone else without my additional written consent.
• I will be informed of all people who will be present at all sites during my telehealth service.
• I may exclude anyone from any site during my telehealth service.
• I may see an appropriately trained staff person or employee in-person immediately after the telehealth service if an urgent need arises OR I will be told ahead of time that this is not available.

I have read this information carefully, and will call either 402-926-4373 (Omaha) or 402-423-6464 (Lincoln) if I have any questions regarding this information.

Behaven Kids Omaha

8922 Cuming St.

Omaha, NE 68104

 

Behaven Kids Lincoln

1145 High St.

Lincoln, NE 68502