CCD Counseling PA
Telehealth Statement of Understanding
This statement of understanding is in addition to the agreements already contained in the client’s original “Client Information and Consent” and “Notice of Privacy Practices.”
1. The client wishes to receive services via online, telephone or video platform. The client understands what other modalities are available to them. The client understands that the therapist or the client can discontinue the telehealth session if either believes it is not adequate for the situation.
2. Much of the counseling process will remain unchanged. The client and therapist will spend the session working toward the goals identified in the client’s treatment plan, just like they do in face to face sessions. However, some things will be different because the client and therapist will not be in the same room.
3. These electronic modalities offer advantages and disadvantages. Advantages include client convenience, ease of access and comfort. Disadvantages include not being able to read non-verbal cues as easily, the possibility of a sudden disconnection or other technical difficulties, and a more complex environment for maintaining privacy. There are additional advantages and disadvantages, including some that we may not anticipate.
4. The client understands the relative privacy risks for each modality. CCD uses a video platform that utilizes encryption. Phone conversations are not encrypted. Unlike face-to-face counseling, the therapist cannot guarantee the same degree of confidentiality since telehealth partially takes place in a space outside of the therapist’s control. This means the client has to take full responsibility for where they decide to initiate telehealth and how they will protect the confidentiality of my conversation.
5. In addition to the fee for service, the client understands that depending upon their internet or phone plan, they may incur additional expenses or the use of available minutes in their phone/data/internet plan.
6. Certain situations, including emergencies and crises, are inappropriate psychotherapy services via telehealth. If the client is in crisis or in an emergency, they should immediately call 911 or seek help from a hospital or crisis-centered health care facility in their immediate area.
7. Rules that govern your therapist’s service delivery include requirements about the client’s location during telehealth, so be sure to tell them if you are not at your home or if your home address has changed.
By signing this form, I certify:
I have had a direct conversation with my therapist, during which I had the opportunity to ask questions in regard to this procedure. I have read or had this form read and/or had this form explained to me. I fully understand its contents including the risks and benefits of the counseling via telehealth. I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.