Please read this form in its entirety to ensure that you understand the differences between traditional face-to-face counseling/psychiatric care and counseling/psychiatric care that is delivered via online video portal. Please sign to indicate your understanding and provide your consent for treatment, and mail or fax the form to Lifescapes Counseling Associates, PLLC at 950 Windy Rd, Suite 305, Apex NC 27502, Fax 919.303.5986. You can submit via email to email@example.com.
PRIVACY & CONFIDENTIALITY
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Likewise, it is expected that you will also keep our communications confidential and you understand that all records of communication between client and therapist remain the property of your contracted therapist at Lifescapes Counseling Associates, PLLC. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you reviewed with this form.
Confidentiality of E-mail, Cell Phone, Video and Fax Communication: Therapeutic email exchanges are delivered via HIPAA approved email providers. You agree to communicate with your counselor/medication provider online using encrypted email service determined to be suitable by Lifescapes Counseling Associates, PLLC. If you choose to email your counselor from your personal email account, please limit the contents to pragmatic issues such as cancellation or change in contact information. Your counselor/medication provider will not respond to personal and clinical concerns via regular email in the interest of protecting your privacy. If you call your counselor, please be aware that unless we are both on land line phones, the conversation is not confidential. Likewise, text messages are not guaranteed to be confidential. If you send a fax, our fax line is in a secure location. Any computer files referencing our communication are maintained using secure and encrypted measures. If you wish to use email as a way to “journal” information between sessions, you understand that your counselor may not have the opportunity to review your journal emails until our next scheduled session. You understand that emails between sessions that contain confidential information should be sent utilizing encryption. Video sessions will be done using an encrypted video portal and will not be recorded.
Your counselor/medication provider will make every effort to keep all information confidential. Likewise, it is important that you carefully determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors and friends. Please only communicate through a computer that you know is safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all online counseling sessions and emails. If we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If reconnection is not possible, email or call our office at 919.303.0273 to schedule a new session time.
We acknowledge that the predominant modality of distance counseling we will use will be interactive video. You understand that the only form of teletherapy/telemedicine that is covered by insurance companies is synchronous (real time) interactive video with audio. Therapeutic emails and phone calls are not covered by insurance and may incur an additional fee. You understand that not all insurance plans cover online mental health services, and some plans may require authorization in advance. Our licensed clinicians are in-network providers for most insurance companies, but there are variations among our staff regarding which networks they are in. We will do our best to make sure that services offered are covered, however, please understand that quotation of benefits by insurance companies does not constitute a guarantee of coverage.
TELEPHONE & EMERGENCY PROCEDURES
If you need to speak with your counselor between sessions to alert them of an emergency, please call 919-303-0273. Your call will be returned as soon as possible. Messages are checked daily (but not at night). Messages are checked less frequently on weekends and holidays. If an emergency situation arises that requires immediate attention, you may call the emergency National Suicide Hotline at 800-784-2433 or dial 911. If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911 or go to a hospital emergency room.
DUAL RELATIONSHIPS & SOCIAL NETWORKING
Not all dual relationships are unethical or avoidable. However, romantic or sexual involvement between therapist and client is never part of the therapy process, nor are any other actions or dual relationship situations that might impair your counselor’s objectivity, clinical judgment, or therapeutic effectiveness or that could be exploitative in nature. In addition, your therapist will never acknowledge working therapeutically with anyone without his/her written permission. In some instances, even with permission, your counselor will choose to preserve the integrity & privacy of your working relationship. For this reason your counselor will not accept any invitations via social or professional networking sites from clients, nor will your counselor respond to blogs written by clients or accept online comments from clients.
During the initial intake process and the first couple of sessions, your counselor will assess if he or she can be of benefit to you. In the case of online counseling, the assessment will include your suitability to psychotherapy delivered via technology. Counselors do not accept clients who, in their opinion, they cannot help. In such a case, your counselor will provide you with referrals that you may contact. Your counselor will also assist you with appropriate referrals at any time during your work together and at or following termination.
IMPORTANT ADDITIONAL CONSIDERATIONS
You as the client understand that phone and email sessions have limitations compared to in-person sessions, among those being the lack of “personal” face-to-face interactions, difficulties with technology and internet connection, and the lack of certain connection cues in the therapeutic relationship. You understand that online psychotherapy is not a substitute for medication under the care of a psychiatrist or doctor. You understand that online therapy is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. As stated previously, if a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room. You also understand that your counselor follows the laws and professional regulations of the State of North Carolina (USA) and the counseling treatment will be considered to take place in the state of North Carolina (USA) as well as the state in which you reside. If you live in a state that does not allow treatment by out-of-state providers who are not also currently licensed in that state, we will be unable to provide distance counseling/telemedicine services.
If you are requesting telemedicine services/psychiatric medication management, please note that it is not permissible in NC to prescribe controlled substances for pain management via online/video means. Electronic prescribing will be utilized for most prescriptions, although certain additional limitations may apply, and the provision of medication management via online means will entail the same appropriate care and scrutiny as we employ in face to face services in order to ensure your safety and best interest.
Your signature below indicates that you have reviewed the information available on our practice website and have read and understand this Informed Consent, the HIPAA Notice of Privacy Practices, and the Professional Disclosure Statement of your specific therapist (if required by the relevant licensure board). Additionally, your signature indicates that you are over 18 years old and able to initiate mental health treatment on your own behalf. If you are under 18 years of age, you certify that the parent/guardian signature below is valid.