I hereby consent to engage in Telemental Health Therapy with Jennifer Van Rossum, LPC – 5Peaks, LLC. I understand telehealth includes the practice of mental health care delivery, diagnosis, consultation, treatment, transfer of medical/mental health data and education using interactive audio, video, and/or data communications (e.g., internet, email or telephone based therapy).
Benefits of Telemental Health
Some benefits of telehealth may include: convenience, increased comfort in expressing thoughts and emotions, elimination of transportation difficulties, more efficient use of time, decreased missed appointments due to weather and increased opportunity to prepare in advance for therapy sessions.
Risks of Telemental Health
I understand that there are risks and consequences from telehealth. These may include, but are not limited to: the transmission of my mental health information could be disrupted or distorted by technical failures; increased potential for other people to overhear sessions if I am not in a private location; and/or misunderstandings can more easily occur using this platform of communication.
Efficacy of Telemental Health
Most research is showing telehealth to be a legitimate, effective therapy option. However, I understand that telehealth-based services and care feels and is different from face-to-face service. If I or my therapist believes I would be better served by face-to-face service, she or I can request termination of telehealth services and start face-to-face sessions. If I do not live in the same location as my therapist, I will be referred to a psychotherapist in my area who can provide such service.
I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder and dependent adult abuse; expressed threats of violence towards an identifiable victim; where I make my mental or emotional state an issue in a legal proceeding. (See also Office Policies and HIPAA Notice of Privacy Practices forms, provided to me, for more details of confidentiality and other issues.)
I also understand that the dissemination to other entities of any personally identifiable images or information from the telehealth interaction shall not occur without my written consent.
I have read and understand the information provided above and/or I have discussed it with my psychotherapist and all of my questions have been answered to my satisfaction. My electronic signature serves as my agreement.