TELEBEHAVIORAL HEALTH SERVICES AGREEMENT AND INFORMED CONSENT

Hicks Counseling Services
Beverly Hicks, M.Ed.
NC: LCMHC, CCS, CADC
TX: LMFT, LCDC2301

Mailing: 9650 Strickland Rd. Suite 103-424
Raleigh, NC 27615

Office: 919.904.4257
Fax: 866.594.1848
www.hickscounseling.com

Hicks Counseling Services, PLLC

Beverly Hicks, M.Ed.NC: LCMHC, CCS, CADCTX: LMFT, LCDC
TELEBEHAVIORAL HEALTH SERVICES AGREEMENT AND INFORMED CONSENT
1. As a Client of Hicks Counseling Services, I agree to the following:
  Unless we explicitly agree otherwise, our telemental health exchange is confidential. Any personal information you choose to share with me will be held in the strictest confidence. Just as for my face-to-face clients, I will not release your information to anyone without your prior approval, or I am required to do so by law. In North Carolina we are required to notify authorities if we become convinced a client is about to physically harm someone; or if they are abusing, or about to abuse, children, the elderly, or the disabled.
2. You understand that our telemental therapy occurs in the state of North Carolina and is governed by the laws of that state. In a manner of speaking, you use modality to visit me in my North Carolina office; where we meet to do our work.
3. Helping you build the life you want is what our exchange is all about. We should not continue any process that is counter-productive in that respect. Either of us is free to terminate our relationship at any time and for any reason. If you decide to terminate, I believe it would be to your benefit to write me a short note staying the reasons for your leaving. There would, of course, be no charge for such a note. In the unlikely event, I become convinced our teletherapy is not in your best interests (see below), I will explain that to you and suggest some alternative options better suited to your needs.
4. While telemental therapy is a great way to get help with many of life’s problems, overwhelming or potentially dangerous challenges are best met with face-to-face professional support. You understand that our telemental therapy is neither a universal substitute nor the same as, face-to-face psychotherapy treatment. You accept the distinctions made using telemental therapy vs. face-to-face psychotherapy. You accept that telemental therapy does not provide emergency services.
5. You are responsible for information security on your computer. If you decide to keep copies of our emails or communication on your computer, it’s up to you to keep that information secure. Unfortunately, I cannot guarantee the security of our e-mails as they travel between our computers but VPCare360 is encrypted, so it is confidential. It is possible, though unlikely, to intercept e-mails in transit. If you are concerned about that possibility, please consider the option to use the email service inside VPCare360 to convey any confidenBal information you may be worried about.
6. Our telemental therapy is a means by which you, the e-client, can receive coaching, counseling, information and guidance from an experienced psychotherapist. It is perhaps most accurately perceived as a process creating, over time, a trusting and collaborative relationship. In our collaboration, you retain the right to determine which topics we cover and the depth of consideration each receives. In other words, as an e-client, you are free to contribute or withhold any information you choose. Moreover, you are under no obligation to apply information and/or opinions I contribute to our telemental therapy. While I hope that you will find our exchange useful in your efforts to help yourself and improve your life, it is not possible to guarantee that; despite the ever-increasing positive feedback from e-clients, telemental therapy is best considered experimental until it’s efficacy has been validated scientifically. There are no other explicit or implied commitments in our telemental therapy relationship.
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Hicks Counseling Services, PLLC

TELEBEHAVIORAL HEALTH SERVICES AGREEMENT AND INFORMED CONSENT