Introduction

Telehealth services involve the use of real-time direct delivery of electronic communications to provide Outpatient Behavioral Healthcare Services.  Telehealth services are offered by WCAP Counseling via interactive video conferencing communication. To provide emergency behavioral telehealth care services (e.g., in response to COVID-19), for a short period of time, WCAP Counseling is now offering telehealth services via any audio or video non-public facing remote communication devices (e.g., telephone, cell/smartphone).  Telehealth services may assist in the evaluation, diagnosis, management and treatment of a number of behavioral health concerns. This means that you may be evaluated and treated by your behavioral health care practitioner or specialist from a distant location. Since this may be different than the type of behavioral health care services with which you are familiar, it is important that you understand and agree to the following statements. 

 

The information you share with your provider via Telehealth services may be used for diagnosis, treatment, follow-up and/or education, and may include: your practitioner reviewing your medical record with you or in consultation with a colleague for continuity of care; live two-way audio and video conferencing; output data from electronic health record devices, sound and video files.  Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

• Improved access to behavioral healthcare by enabling a client to remain in a safe, private remote site while engaging with their practitioner.
• More efficient behavioral healthcare diagnostic evaluations, therapy and treatment management.
• Obtaining expertise of a distant specialist.

Possible Risks:

As with any behavioral health service, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of video quality or images) to allow for appropriate healthcare decision making by your provider;
• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment;
• Use of third-party applications to provide Telehealth services potentially introduce privacy risks.
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete client medical records may result in judgment errors;

 

Telehealth may not be the most effective form of treatment for certain individuals or presenting problems.  Arrangements to meet via Telehealth must be made in advance.  Therapists reserve the right to reject requests to meet via Telehealth if they do not think the quality of care for the client is appropriate.

 

By signing this form, I understand the following:

1. I understand that the Telehealth practitioner or specialist will be at a different location from me.
2. I understand that the laws that protect privacy and the confidentiality of medical information also apply to Telehealth, and that no information obtained in the use of Telehealth which identifies me will be disclosed to researchers or other entities without my consent.
3. I understand that use of third-party applications to provide Telehealth services potentially introduce privacy risks.  * In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
4. I understand that I have the right to withhold or withdraw my consent to  the use of Telehealth in the course of my care at any time, without affecting my right to future care or treatment.
5. I understand that my provider (that is, the “presenting practitioner”, will keep an electronic medical record documentation of the Telehealth service in my medical record.
6. I understand that my provider may transmit or share electronically details of my client medical record as permitted by a signed Authorization for Release of Information (ROI) to engage others in my treatment (e.g., primary care physician, Probation Officer, drug screening facility etc...), who are located off-site.
7. I understand that I will be informed if any additional person(s) are to be present other than myself and my behavioral health provider via video prior to, engaging with my provider. I will give my verbal permission prior to the entry of the additional person(s).  I understand that my practitioner has the right to turn down the opportunity for others to engage in my treatment if they deem so to possibly decrease the quality of  my care.   
8. I understand that I may expect the anticipated benefits from the use of Telehealth in my care, but that no results can be guaranteed or assured.
9. I voluntarily consent to Telehealth care services provided by my provider and/or their designee, which may include a diagnostic assessment, treatment planning, drugs tests, case management or other recommended treatment considers necessary to treat my health problem.
10. I understand that a variety of alternative methods of behavioral health care may be available to me, and that I may choose one or more of these at any time. My behavioral health care provider has explained the alternatives to my satisfaction.

Client Consent to The Use of Telehealth

I have read and understand the information provided above regarding Telehealth. I have discussed it with my provider, and all of my questions have been answered to my satisfaction.

I hereby give my informed consent for the use of Telehealth services in my behavioral health care. I hereby authorize Whitehall CAP Inc., WCAP Counseling to use Telehealth in the course of my diagnosis and treatment. I also consent to WCAP Counseling utilizing any audio or video non-public facing remote communication device to provide my care via diagnostic assessments and/or regular therapy sessions amidst the COVID -19 emergency.