Please read the information below carefully and completely; you are encouraged to ask any questions necessary to ensure your full understanding before providing signed consent for yourself or as the Responsible Party on behalf of the Patient named above.

Clinicians at Blue Ridge represent four professional disciplines whose Maryland State Boards define “Telehealth” similarly but reference it by terms that reflect their specialty: “Teletherapy” when provided by a Licensed Certified Social Worker-Clinical (LCSW-C) or a Licensed Clinical Professional Counselor (LCPC), “Telepsychology” when provided by a Licensed Psychologist (Ph.D./Psy.D, and “Telehealth” when provided by a Maryland Licensed Physician (M.D. Psychiatrist)

For the entirety and purpose of this Consent form, the term “Telehealth” is used for all Clinicians at BRBH, regardless of their discipline, except where noted, and is defined as follows: the use of interactive audio, video, audio-visual, or other telecommunications or electronic technology that allows the Clinician to provide mental health services within one’s scope of practice to a Patient who is at a different physical location.

Telehealth does not include communication between a Clinician and Patient by means of telephone calls, e-mails, fax, or text message. However, during certain Federal and/or State of Emergencies, an Executive Order(s) may permit, for a limited time, Telehealth services be provided by audio-only interactions (i.e., by telephone); the Clinician will inform a Patient when and under what conditions this is allowed.

This Consent is specific to Telehealth services. It does not replace but is used in conjunction with the Informed Consent document (“BRBHS Patient’s Rights and Responsibilities Form”) required to be signed by all Patients prior to the start of mental health evaluation/treatment at Blue Ridge Behavioral Health (BRBH/Blue Ridge).

Clinicians at Blue Ridge will provide Telehealth services by conducting online sessions using Doxy.me, a HIPAA compliant videoconferencing software platform that meets the standards of encryption and privacy protection. It also provides a Business Associate Agreement for the Clinician to sign. There is no fee for Patients to use Doxy.me, and instructions will be given for how to use the service before connecting for online sessions.

Telehealth provides a way for a Clinician to deliver mental health services when circumstances such as time, travel restrictions, or health impairments, for example, prevent these services from occurring at the Clinician’s office. However, it’s important to understand fully the rights, risks, limitations, and responsibilities stated below for the Patient and/or Clinician when using Telehealth.

• Clinicians must provide Telehealth in compliance with State laws and regulations, including those regarding the locations of the Clinician and Patient during the Telehealth session. The Patient agrees to be honest about his/her/their location and emergency contact information the Clinician may request. Failure to do so may result in the termination of the use of Telehealth and/or the end of the Patient-Clinician relationship. Should this occur, the Clinician will discuss the plans for transfer of the Patient’s mental health care, which will include providing referral sources.
  
  
• When Telehealth uses videoconferencing for the delivery of services, a Patient will be participating in virtual “face to face” treatment sessions rather than in-person “face-to-face” sessions at the Clinician’s office. The Patient understands he/she/they may experience sessions somewhat differently and accepts that the quality of transmitted information may affect the quality of services provided.
  
  
• Telehealth comes with limitations specific to Psychiatrists that may impact the quality of care a Psychiatrist can provide. The Psychiatrist cannot monitor a Patient’s vital signs, including blood pressure, height, and weight. The Psychiatrist may not be able to order or obtain laboratory studies (for example, blood work, urinalysis, EEG, or EKG) that provide information necessary for Patient care. The Patient understands that if the Psychiatrist does not have information about the Patient’s vital signs and/or required laboratory studies, it could limit the decisions the Psychiatrist can make regarding management of prescribed medications. This includes decisions about starting medication, changes in medication(s) currently prescribed, and/or the dosing of these medications.
  
  
• The Patient is responsible for providing his/her/their own equipment that will allow the Patient to connect with the Clinician for Telehealth sessions. This includes a computer, smartphone, or tablet, a webcam either built into a device or added to it, and non-public Internet access to conduct the sessions. The Clinician and Patient each have the responsibility to ensure the security of one’s own equipment and of the internet access at one’s own location.
  
  
• The Patient understands that Telehealth, when provided online, is technical in nature and that problems may occur due to problems with internet connections or interruptions related to any equipment or software being used and/or services provided by a 3rd party. The Clinician has no control over any of these situations, nor guarantees that any services will work as expected.
  
  
• If something occurs to prevent or disrupt any scheduled appointment due to technical complications, and the session cannot be completed via online videoconferencing, the Patient agrees to contact the Clinician to reschedule.
  
  
• The Patient understands there are no guarantees for privacy protection when any information is transmitted by the internet. The Clinician will inform a Patient if Doxy.me provides notification that a data breech occurred.
  
  
• The Patient understands there is a risk of being overheard by anyone nearby if the Patient is not in a private room while participating in Telehealth. It is the Patient’s responsibility to arrange a location with sufficient lighting and privacy, free from distractions or interruptions, for one’s Telehealth sessions. It is the Clinician’s responsibility to do the same in the environment in which sessions are conducted.
  
  
• The Patient agrees to inform the Clinician of other persons knowingly present in the location for the Telehealth session. The Patient understands the Clinician may ask others to leave the location or may end the Telehealth session if there is concern that confidential information will be compromised or the presence of the person(s) interferes with the productivity of the online session.
  
  
• The Patient understands and agrees that there will be no recording of any of the online sessions by either the Clinician or the Patient. It is also understood that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without the Patient’s written permission, except where disclosure is required by law.
  
  
• The Patient has the right to access the written records of the Patient’s Telehealth sessions in accordance with the same laws that permit the Patient to access written records of any in-person sessions with the Clinician.
  
  
• The Patient accepts that Telehealth does not provide emergency services and can limit the ability for the Clinician to fully evaluate and determine if the Patient requires emergency care. The Patient understands that when experiencing a mental health emergency, the Patient can call 9-1-1 or proceed to the nearest hospital emergency room if able to do so safely. Patients who are actively at risk of harm to self or others are not suitable for Telehealth services. If this is the case or becomes the case in the future, the Clinician will recommend more appropriate services.
  
  
• The Patient understands that he/she/they will be treated with the same standard of care that would be provided if treated in person. It is also understood that results of Telehealth cannot be guaranteed nor assured. There are risks and benefits associated with any form of mental health services and despite the efforts of the Patient and the Clinician, the Patient’s condition may not improve and in some cases, may even worsen.
  
  
• The Clinician may determine that Telehealth sessions are not in the Patient’s best interest and will discuss other forms of mental health services better suited to the Patient’s needs.
  
  
• The Patient understands the right to withhold or withdraw consent to participate in Telehealth services at any time without affecting the right to future care or treatment.
  
  
• The Patient has the responsibility to keep any scheduled telehealth appointments and will be charged for missed appointments or cancellations for which 24-hour’s notice, not to include weekends/holidays, has not been given.
  
  

In signing this Consent form, I acknowledge that I have read and understand all the terms and information provided herein. I was given ample opportunity to ask questions or seek clarification for anything I did not understand or that was unclear to me. I understand I will be responsible for payment of Telehealth services that are not covered by the Patient’s Insurance Provider. I voluntarily consent for the Patient to participate in Telehealth for mental health evaluation/treatment services.

I understand that due to problems that may occur with internet connections for the Patient and/or Clinician, it may be difficult to connect/reconnect for scheduled Telehealth sessions. Therefore, I authorize use of the following email address and cell phone number as options for the Clinician when arranging the sessions. I also agree to contact the Clinician to reschedule if a session could not be completed.