The purpose of this document is to inform you, the client, an adult, 18 years or older whom resides in the state of Ohio about aspects of technology assisted counseling services via Online or Phone. Please read this entire document, sign, and submit.

RIGHTS WITH RESPECT TO ONLINE/PHONE THERAPY

The laws that protect the confidentiality of my personal information also apply to online/phone therapy. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. You may decline any service at any time without jeopardizing your access to future care.

CONFIDENTIALITY

Confidentiality is a fundamental principle of psychotherapy. Anything you discuss with the therapist and the information contained in your file will remain completely confidential with the exception of the following circumstances: if you present a serious danger to yourself or another person, if you report physical or sexual abuse of a minor, or exploitation of an incapacitated adult, if a valid subpoena is received for your records, or your records are otherwise subject to a court order or other legal process requiring disclosure.

RISKS AND BENEFITS

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing unpleasant aspects of your life.  However, psychotherapy has been shown to have benefits for individuals who undertake it.  Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.  But, there are no guarantees of any positive outcome. Psychotherapy requires active effort on your part. In order to be most successful, you will have to work outside of sessions on matters discussed with your therapist.

REFFERAL

Technology assisted counseling may not be appropriate for many types of clients including those who have numerous concerns over the risks of internet counseling, clients with active suicidal or homicidal thoughts, and clients who are experiencing active manic/psychotic symptoms. An alternative to receiving services online or by phone would be to receive services in person. You will be given a referral that would be more practical or beneficial for you.

EMERGENCY

I accept that technology assisted counseling does not provide emergency services. I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support.

PRIVACY OF THE THERAPIST

The therapist has a right to privacy and restricts the use of any phone or video copies or recordings by the client.

PROFESSIONAL FEES

Fees for online/phone therapy is the same. Online therapy or telephone sessions are paid in advance and payments are made via Square Registrar. I understand that I must pay for each service prior to receiving the services.

CANCELLATION POLICY

You must give 24 hours notice in order to cancel your therapy/phone session or you will be charged the full fee. I understand that I am responsible for all charges incurred, for no shows, missed appointments or failure to give 24 hour cancellation notice. You will not be expected to pay for the session if you have major problems with your connection.

 CONSENT TO PSYCHOTHERAPY

I have read and understand the information provided above regarding online/phone therapy, have discussed it with my therapist, and all of my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of online/phone therapy services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of online/phone therapy services for treatment under the terms described herein.

I have read a copy of the Notice of HIPPA Privacy Practices, Client Rights, and Payment Polices & Fee Agreement PART 1 - documents.

By my signing & submitting this document, you indicate that you have read, understood, and agree to the terms of this document.