Access Counseling Services, LLC
Tele-Health Informed Consent

Tele-Health is the practice of delivering health care services via technology assisted media or other electronic means (phone, computer, tablets) between a practitioner/therapist/case manager and a client/patient who are in two different locations.

I understand the following with respect to tele-health services:

1. I understand that I have the right to withdraw consent at any time.

2. I understand that there are risks, benefits, and consequences associated with tele-health, including but not limited to:

       a.Disruption of transmission by technology failures.

       b. Interruption and/or breaches of confidentiality by unauthorized persons,

       C. Limited ability to respond to emergencies.

3. I understand that there will be no recording of any of the online sessions by either party.

4. I understand that all information disclosed within sessions and written records pertaining to authorization, except where the disclosure is permitted and/or required by law i.e. child or elder abuse, danger to self or others, third party payers.

5. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to tele-health unless an exception to confidentiality applies i.e. child or elder abuse, danger to self or others, third party payers.

6.I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that tele-health services are not appropriate, and a higher level of care is required.

7. I understand that during a tele-health session, technical difficulties could occur and result in service interruptions. If this occurs, end and restart the session. If unable to reconnect within ten minutes, please call to re-schedule. If you are having an emergency when service is interrupted, call 911 or go to the ER first, and then contact your provider.

8. I understand that my provider(s) may need to contact my emergency contact and/or appropriate authorities in case of an emergency. I agree to update my location and emergency contact information at the beginning of each session. An emergency contact person may be contacted on your behalf in a life-threatening emergency only. The person will only be contacted to go to your location or take you to the hospital in the event of an emergency.

I have read and understand the information provided above. My signature below indicates agreement with the above terms and my consent to participate in tele-health services.