Informed Consent for Telehealth
 
Telehealth involves the use of electronic communications to enable Light of the Rockies to connect with clients using interactive video and/or audio communications and includes the practice of mental health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.
 
Generally speaking, the information provided by and to the client during therapy sessions, including telehealth sessions, is legally confidential and the therapist cannot disclose or release the information without the client’s consent. There are exceptions to this confidentiality, some of which are listed in section 12-43-218 of the Colorado Revised Statutes, and the HIPAA Notice of Privacy Rights you were provided, as well as other exceptions in Colorado and Federal law.
 
I understand that I have a right to access my medical information and copies of my medical records in accordance with the laws pertaining to the state in which I reside.
 
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.
 
I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Light of the Rockies utilizes HIPAA Compliant audio and/or video transmission to deliver telehealth.
 
In an emergency or crisis situation, which could include situations where the client is a threat to themselves, others, and/or national security, the client will commit to calling 911 or going to the nearest hospital emergency room.
 
I understand that if my counselor believes I would be better served by another form of intervention, I will be referred to another mental health professional.
 
This document is supplemental and does not amend any of the terms of prior agreements and extends through the duration of your treatment at Light of the Rockies. Agreement can be revoked in writing at any time.
 
I have read and understood the preceding information regarding telehealth and my rights as a client or as the client’s responsible party, have discussed it with my counselor, and all of my questions have been answered to my satisfaction and I consent to engage in telehealth treatment, for either myself or my child, with Light of the Rockies.