Telehealth & Video Recording

Telehealth involves the use of electronic communications to enable Behavioral Learning to connect with individuals using interactive video and audio communications. Telehealth includes the implementation and delivery of Clinical Behavior Analysis, counseling, consultation, treatment, referral to resources, and education. The laws that protect the confidentiality of personal information also apply to telehealth. Behavioral Learning is recognized as an essential service and able to continue providing direct in-person services or transition individuals and families to a telehealth format, when appropriate. After conducting an individualized risk assessment of you or your child’s needs, we have determined that your (or your child's) treatment will include telehealth.

Additionally, telehealth sessions offer a unique opportunity for video recording. Video recordings are commonly used for consultation, training and research in individual, family and/or group therapy. At Behavioral Learning, videos are used for the purposes of professional training, consultation and/or improving service in individual supervision (between the counselor and their supervisor) and/or group supervision (between the counselor, the supervisor, and other registered interns), only.

I decline to have my sessions video recordedI consent to have my sessions video recorded

I understand that I have the following rights and risks:

1. I understand that I have the right to withhold or withdraw my consent for the use of telehealth and/or video recording at any time, without affecting my right to future care or treatment.2. I understand that the laws that protect the confidentiality of personal information also apply to telehealth and/or video recorded sessions.3. I understand that the alternative to the form of therapy recommended above, maybe an interruption in treatment that could lead to an increase in severity of challenging behavior and/or increase the likelihood that myself, or my child,experiences a significant regression in skills.4. I understand that there are potential negative consequences from telehealth and/or video recording, including but not limited to, the possibility, despite reasonable efforts on the part of the therapist 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.5. I understand that telehealth includes anticipated benefits, such as continuity of care and skill development, while also decreasing the risk that a member of my household, could be exposed to illness.6. I understand that video recording includes potential benefits, such as enhancing the effectiveness and quality of my personal treatment, in addition to contributing to the development of future professionals.7. I understand that I have the right to request a copy of my video and reserve theright to erase my video, at any time.8. I understand that opting to continue in-person therapy services increases the likelihood that a member of my household, could be exposed to illness.

I have read and understand the information provided above regarding telehealth and video recording and been informed of my risks, have discussed these with Behavioral Learning, and all of my questions have been answered to my satisfaction.

I hereby give my informed consent to participate in treatment, as indicated above, and understand the terms described herein.

This waiver will remain in effect for one year from date of signature.

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