Liberated Counseling, LLC

• This form will go over a little bit about telehealth, how to electronically complete intake and other paperwork, and will help you set up the tools for our video telehealth sessions.
• We will use secure, encrypted technologies that are free to you for video sessions.
• Telehealth has both benefits and risks, which we will be monitoring as you proceed with your work.
• You can stop work by telehealth at any time without prejudice.
• You will need to participate in creating an appropriate space for your telehealth sessions.
• You will need to participate planning for technology failures, mental health crises, and medical emergencies.
• I follow security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy.

Telehealth means the providing of mental health counseling through secure video software. Services delivered via telehealth rely on a number of electronic, Internet-based, programs. I provide telehealth via a secure application called vsee messenger or a secure website called doxy:

• V see messenger can be d o wnloaded for free here: https://my.vsee.com/download
• If you prefer , we can also meet thr ough the secure doxy website . My d oxy ’ s website is https://doxy.mee/sr atcli ff
• Yo u will need access to high speed Internet service for your telehealth session .
• If you have any questions or con cerns about the above tools, please let me know .

• Receive services when you are unable to travel to the service provider’s office.
• Receive services at times or in places where th e service may not otherwise be available.
• Receiv e services in a fas hion that may be more conv enient and less prone to delays than in - person meetings.
• Re ceive servi ces without potential risks of transmission of COVID 19 or other transmittable vir uses.
• The unique characteristics of tele health media may a lso help some peopl e make improved progress o n health goals  that may not have been otherwise achievable without tele health .

Telehealth services can be impacted by technical failures, may introduce risks to your privacy, and may reduce my ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples:

• Internet connections and cloud services could cease working or become too unstable to use .
• Compu ter or smartphone hardwa re can have sudden failures or run out of p ower, or local power servi ces can fail .
• Interruptions may disrupt services at important moments, and I may be unable to reach you quickly .

• Alth ough it is well validated by research, serv ice delivery via tele health is not a good fit for every person. I will  continuously assess if working via t ele health is appropriate for your case. If it is not appropriate, I will help you find  in - person providers or shi ft to in - person sessions .
• Please talk to me if you find the tele he alth media so difficult to use that it distracts from the services being pr ovided,  if the medium causes trouble focusing on your services, or if there are any other reasons why the telehealth medium seems to be causing problems in receiving services.
• Bringing your concerns to me is often a part of the process. You also have a right to stop receiving services by telehealth at any time without prejudice.

You will be responsible for creating a safe and confidential space during sessions. Please consider:

• D ress as you would if we were meeting in an office appointment .
• If you have a headset with a mi crophone, please use it as this helps pr oduce better a udio and privacy.
• Ple ase be in an environment where you are alone and h ave goo d a ccess to high s p eed internet.
• Please limit distractions such as multi - tasking . Please turn on do not disturb if you are meeting on your cell phone.
• Have your computer or tablet on a firm surface if possible.
• Please avoid walking around with your de vi ce , as this can make me dizzy.

If you need to get ahold of me in between sessions, here are some contact methods and considerations:

• The best way to contact me betwe en sessions is by email steve@liberatedcounseling.com   or telephone 505 - 50 4- 54 49 . Please note that neither email nor my telephone number are to be used during a crisis .
• I will respond to your messages a s soon as I can. P lease note that I may not respond at all on weeken ds or holidays.
• O ur work is done primarily during our appointed sessions, which will generally o ccur during my business hours  Monday thru Thursday from 10am t o 7p m .
• Contact between sessions should be limited to confirming or changing appointment times.

As a recipient of telehealth services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with me.

• I will require you to desi gnate an emergency contact at the intake appointment . You will need t o provide permission  for me to communicat e with this person about your care during emergencies.
• Crisis services include Tele phone crisis lin es ( 800 - 273 - 8255 or 505 - 277 - 3013) , call ing 911 , or go immediately to the nearest Emergency Room.
• Except where otherwise noted, I employ software and hardware tools that adhere to security best practices and  applicable legal standards for the purposes of pr otecting your privacy and ensuring that record s of your health care  services are not lost o r damaged.
• As wit h all things in tele health , however, you also have a role to play in maintaining your security. Please use  reasonable security protocols to protect the privacy of your own health care informati on. For example: when  communicating with me , use devices and se rvic e accounts that are protected by unique passwords that only you  know. Also, use the secure tools that I have supplied for communications (e.g. V see) . Fo r more infor mation please  see my spec ific recommendations for electronic security and safety here : http://steveratcliff.com/techrec.pdf

 

Vsee messenger can be downloaded for free here: https://my.vsee.com/download

• After you download and install vsee messenger onto a tablet, computer, or smart phone, you will need to se t up an account. This process if free but will include using an ema il address for that account.
• If you have pro blems downloading vsee mes senger, let me know and I can email you a download invite
• After you have set up the application and account, let me know what email address you used, and I will  reach out to you through the application to connect us.
• After we are connected, we can send messages, do video sessions, and exchange files securely through the end-to-end encryption that vsee messenger uses.
• A video showing some of the basic functions of the vsee messenger application is here:  https://youtu.be/XZlCfj07MUQ  

If you prefer, we can also meet through the secure doxy website, which is https://doxy.me/sratcliff

• Click on the link and check in a few minutes prior to our appointment time using whatever name you’d like.
• It will ask you to enable access to your microphone and camera. Click yes.
• I will start the appointment at our appointment time.
• This webpage is a tutorial for doxy https://help.doxy.me/en/articles/3751218-how-to-check-in-as-a-patient

Call me at 505-504-5449 if there are technical difficulties.

Please do not record video or audio sessions without my consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. I will not record video or audio from our sessions.

• Currently , t elehealt h services are only permitted to reside nces of New M e xico, Oregon,  and Florida due to licensure law  restrictions. M any insurance companies cover some or all of the cost of services delivered by telehealth . Currently ,  many New Mexico insurance plans including New Me xico Medicaid cover telehealth services . If you ha ve question s  about coverage of telehealth , please contact your insurance company.
• Copays and deductibles will be due at the time of s ervice during a tel ehealth session similar to an i n - office session.  These fees will be collected by cash, check, credit ca rd, H SA, or FSA means.
• Any credit card, debit card, HAS , or F SA payments will be collected using a secure service called I vy , which keeps  your c ard on file. I will never charge you r card without your perm is sion . Your signature at the bottom of this form  indicate s your consent to Ivy maintaining your chosen card on file. I can delete your c ard i nformation upon request.

Prior to our first appointment and periodically throughout therapy, we will need to complete paperwork. I have made my forms fillable online for your convenience. Here are some tips to help you fill out these forms:

• You may fill out forms securely through the links on my website: www.steveratcliff.com

OR

• You can fill out forms securely through a website called jotform. If you would like the link to fill out documents electronically, please check on my website www.liberatedcounseling.com  or ask me!
  
  

Our signatures below attests to the fact that:

• WE have residency in either the sta te of New Mexico, Oregon, or Flori da.
• WE agree to participate in telehealth - based psycho therapy.
• WE have read, unders tood, and ag ree to follow the above policies.
• WE con sent to having our electronic payment information st ored on Ivy.