I hereby consent to engage in teletherapy with Emilie Moreau, MA. I understand that “teletherapy” includes consultation, treatment, transfer of medical data, emails, telephone conversations, and education using interactive audio, video, or data communications. I understand that teletherapy also involves communicating my medical/mental information, both orally and visually.
I understand that I have the following rights concerning teletherapy:
1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
2. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are discussed in detail in the general Informed Consent and/or Confidentiality Statement I have previously received.
3. I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of Emilie Moreau, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
4. I also understand that teletherapy-based services and care may not be as complete as face-to-face services. I also understand that if Emilie Moreau believes I would be better served by another form of therapeutic services (face-to-face services), I will be referred to a professional who can provide such services. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy and that despite my efforts and the efforts of my psychologist, my condition may not improve, and in some cases, may even get worse. I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured.
5. I accept that teletherapy does not provide emergency services. If I am experiencing an emergency situation, 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.
6. I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.
7. I understand that while email and/or text may be used to communicate with Emilie Moreau, the confidentiality of emails and texts cannot be guaranteed. I understand that electronic communication should be used for logistical purposes, only, and not for the transmission of personal or clinical material.
8. I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law. I have read, understand, and agree to the information provided above.