Telehealth allows your therapist to diagnose, consult, treat, and educate, using interactive audio, video, or data communication regarding your treatment.
I hereby consent to participating in psychotherapy via telephone or the internet (hereinafter referred to as Telehealth)
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 medical information for in-person psychotherapy.
Any information disclosed by me during my therapy, therefore, is generally confidential. There are, by law,exceptions to confidentiality, including mandatory reporting of child abuse harm to self or others, requestsfor records in a legal situation.
Further, I understand that the dissemination of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my written consent.
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.
Thus, I understand that while I may benefit from Telehealth, results cannot beguaranteed or assured.
I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding mytreatment could be disrupted or distorted by technical failures or could be interrupted or could beaccessed by unauthorized persons.
In addition, I understand that Telehealth treatment is different from in-person therapy and that if my therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be scheduled in person appointments only.
I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.
I understand that electronic communication cannot be used for emergencies or time-sensitive matters.
I understand that electronic communication should never be used for emergency communications orurgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.
I have read and understand the information provided above. I have the right to discuss any of this information with my therapist, and to have any questions I may have regarding my treatment answered to my satisfaction.
I understand that I can withdraw my consent to Telehealth communications by providing written notification to Prepare to Change.
My signature below indicates that I have read this Agreement and agree to its terms.