RRCS Telehealth Consent Form

Name*

Client First NameClient Last Name

Date of Birth*

MonthDayYear

Telehealth services allow my Therapist &/or BHCM to assess, diagnose, consult, treat, and educate using interactive audio, video, or data communication regarding my treatment. Telehealth uses electronic systems to incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data, and includes measures to safeguard the data and ensure its integrity against intentional or unintentional corruption.

I voluntarily consent to participate in Telehealth services for the purpose of receiving mental health services with Red Road Counseling Services.

I understand I have the following rights under this agreement:

I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my information for face-to-face services. Any information disclosed by me during a Telehealth session is confidential. By law, there are exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my clinician has the right to break confidentiality to prevent the threaten of danger.

Initials*

I understand I am responsible for placing myself in a private location during my session.

Initials*

I understand that the distribution of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my written consent.

Initials*

I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all clients will be effective.

Initials*

I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.

Initials*

I understand that there are risks unique and specific to Telehealth, including, but not limited to, the possibility that my Telehealth sessions or other communication with my clinician regarding my treatment could be disrupted or distorted by technical failures or could be interrupted.

Initials*

I understand that the clinician will be at a different location from me.

Initials*

I have read and understand the information provided above. I understand that I have the right to discuss any of this information with my clinician and to have any questions regarding my treatment answered to my satisfaction.

Initials*

I understand that I can withdraw my consent to participate in Telehealth services by contacting Red Road Counseling Services, LLC by phone at 405-990-0816 or in writing to the following address: 201 N. Broadway Ave. Ste. 100, Moore, OK 73160

Initials*

Client/Guardian Signature*

Date*

Date Signed

Client/Guardian Name*

Signatory's Name

Contact Phone Number*

Area CodePhone Number

Email*

Confirmation EmailContact email address

Please verify that you are human*

Informed Consent for Telehealth Services