• Grace Riddell, LICSW, LCSW-C and Associates

    griddell4@gmail.com | (202) 669-4379 | www.grace-riddell.com

  • Informed Consent & Tele-Mental Health

    1. The laws that protect privacy and confidentiality of medical information also apply to Tele-Mental Health Video TeleConferencing services, (TMH-VTC, referred to hereafter as TMH) and that no information obtained in the use of TMH, which identifies the client, will be disclosed to researchers or other entities without my written consent.
    2. There are two sites participating in a client consultation (the client's location and the provider's location). There are roles and responsibilities for each site regarding confidentiality. Both client and provider agree to make every effort to insure uninterrupted privacy during consultation time.
    3. Current TMH regulation requires the provider to be licensed in the state where the client primarily resides. For this reason, at this time, TMH services can only be provided to DC, MD and VA residents.
    4. Provider and client agree to identify everyone who is participating in the consultation encounter. There will never be anyone else in the room at the provider site, except if explicitly pre-arranged and agreed upon.
    5. If the client has any confidentiality or privacy concerns, the client agrees to address those with the provider.
    6. Sessions will NEVER be recorded, neither by the client nor the provider, without prior written approval.
    7. The client has the right to withhold or withdraw consent to the use TMH at any time.
    8. Client may expect the anticipated benefits from the use of TMH in his or her care, but that no results can be guaranteed or assured.
    9. Healthcare information may be shared with other individuals for billing reimbursement purposes only with prior written consent.
    10. There are inherent risks a given telecommunication technology may pose in both equipment (hardware, software or other equipment components) and the processes used for providing TMH services. A HIPAA-compliant platform will always be used for TMH.
    11. There is the risk of technical failure during a consultation. In this case, provider will telephone the client to make arrangements.
    12. As with face-to-face encounters, the client agrees to implement safety measures in case of imminent danger to self or to another person.

  • By checking this box *
    I have read and understand the information provided above regarding "INFORMED CONSENT FOR TELE-MENTAL HEALTH VIDEO TELE-CONFERENCING SERVICES" and all of my questions have been answered to my satisfaction. I understand the risks and benefits of TMH consultation and I hereby give my informed consent to participate. 

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