Intake Forms Ind-TH

Name*

First NameLast Name

Preferred Name (if different)

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Is it OK to leave detailed voice messages on this phone? Check Yes or No

YesNo

Email*

example@example.com

Is it OK to send detailed messages to this address? Click Yes or No

YesNo

Emergency Contact

Emergency Contact Phone Number

Please enter a valid phone number.

Is it OK to contact this person in case of emergency? Click Yes or No

yesno

Primary Care Doctor

Primary Care Doctor Phone Number

I will not contact without a separate Release of Information

Psychiatrist / Prescriber (if any)

Is it OK to leave detailed voice messages on this phone? Circle Yes or No

Psychiatrist / Prescriber Phone Number

I will not contact without a separate Release of Information

Please indicate the primary reasons you are seeking individual therapy at this time

Please list any prescription medications you are currently taking, including psychotropic medications (such as antidepressants, anti anxiety medications, or mood stabilizers)

Is there anything else it would be helpful for Parke to know?

Client Signature*

Date

Consent to Use Telehealth for Psychotherapy

"Telehealth" or "teletherapy" is defined as delivering health care services (including psychotherapy) via information and communication technologies such as phone or internet, to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient or client's health and mental health care. During a telehealth session, the client is at the originating site (where the client is currently residing) and the health care provider is at the distant site (where the therapist is residing

Disadvantages of telehealth Please be aware that providing therapy using telehealth has drawbacks, including: The connection by which we are communicating may not be stable. Video can freeze, audio can be dropped, the connection may go black. A client in a state of crisis could suffer from losing connection with the therapist. A wired connection to your mobile device is ideal, but if you are using wireless, it should be a very strong connection. Either the therapist or the client can terminate a telehealth session if it is determined that a stable telecommunication connection cannot be adequately maintained during a session. The client's computer may have problems that preclude a telehealth session. The client is strongly encouraged to have the latest operating system and security updates, including installation of current antivirus software, on the computer or smartphone used for telehealth sessions. The therapist can terminate a telehealth session if it is determined that a stable telecommunication connection cannot be adequately maintained. The session may not be secure or confidential unless the client makes it so. The therapist will be located in a private room to ensure security and confidentiality. The client is encouraged to find a place that is private and secure. Sessions can be terminated if it is determined that the location of the client is not private and secure. The client is responsible for ensuring their safety during a call. The therapist may not

be able to assess this as effectively via telehealth. It is not safe, for example, to engage in telehealth while driving. If it is determined that the client is not safe, sessions can be terminated.

Crisis support services may not be available near the client's residence. If the client is in a state of crisis and has no place to get help, there is little a therapist can do from across a wire. The therapist is responsible for identifying local resources based on the client's address (if the client has one), but it is entirely up to the client to access and utilize those resources. There is a lot a therapist cannot see during a telehealth session. Noteworthy mannerisms, gestures, or body language or expression are just a few marks of data that can be missed in a telehealth session. This information could be helpful to a client's progress in

Research on the effectiveness of using telehealth for couple therapy is currently limited. Research on telehealth with individuals has been promising, but few studies have been conducted on telehealth with couples.

/ have read the information offered by my therapist and / understand the disadvantages and limitations of using telehealth/teletherapy as a mode of psychotherapy and mental health treatment.

Client Initials

Advantages of telehealth Telehealth also has some advantages: Telehealth is often more convenient, with flexible location and timing Sessions can take place regardless of weather conditions The client can more easily schedule sessions around a work schedule The client can attend a session from home even when not feeling well The client is not limited to seeing a therapist in the local area, but the therapist must be

located in the state in which the client resides

/ have read the information offered by my therapist and / understand the advantages of using telehealth/teletherapy as a mode of psychotherapy and mental health treatment.

Client Initials

What to expect from the therapist in a telehealth session The following are assurances from therapist during a telehealth session: The therapist will be in a location that ensures the session will be secure, confidential and private The therapist will be using a robust internet connection to optimize a stable connection during the session If connectivity becomes an issue during a session, the therapist will reach out to the client via text or phone call to determine if the session should continue in a different format or be terminated The client is asked to reach out to the therapist via text of phone call if there is difficulty initiating the connection for a scheduled telehealth session The telehealth medium over which the session will occur will meet federal (HIPAA) requirements for security and confidentiality All laws regarding the confidentiality of healthcare information and a client's right to their medical information also apply to telehealth interactions The therapist will locate resources in the client's area to help in the event of a crisis

/ have read the information offered by my therapist and / understand the advantages and disadvantages of using telehealth for my mental health/psychotherapy treatment. / agree and consent to the use of telehealth for the treatment of my mental health concerns. / am aware, however, that the therapist can decide to terminate telehealth sessions if it is determined that consistent audio and video connectivity cannot be maintained throughout the session. / also understand that the therapist may decide to terminate telehealth sessions if it is determined that my condition, problem, or situation requires a level of care that is unsuitable for psychotherapy through telehealth.

Client Signature*

Date

Therapist Signature

Date

Parke Burgess Psychotherapist