I hereby consent to participate in mental health services provided via telemedicine as part of my outpatient psychotherapy. I understand that telemedicine is the practice of delivering clinical health care via technology-assisted media or other electronic means and that the practitioner and the client are in two different locations.
I understand that I have the right to withdraw my consent at any time without my withdrawal’s affecting my right to receive future care, services, or benefits to which I would otherwise be entitled.
I understand that telemedicine is associated with risks and consequences including, but not limited to, the disruption of transmission by technology failures, interruptions and/or breaches of confidentiality by unauthorized persons, and/or limitations on Marcia E. Brubeck’s ability to respond in emergencies. Marcia E. Brubeck, LLC, makes no guarantees or assurances about the results of this service.
I will not record any of the online sessions, and I understand that Marcia E. Brubeck will not do so either. All information disclosed within sessions, and written records pertaining to those sessions, will remain confidential and may not be disclosed to anyone without written authorization except where disclosure is permitted and/or required by law.
I understand that the privacy laws that protect the confidentiality of my protected health information (PHYI) also apply to telemedicine unless an exception to confidentiality applies, such as the governor’s executive orders in a public health emergency; the mandatory reporting of abuse to a child, elder, or vulnerable adult; a danger that I present to myself or others; or, in a legal proceeding, when I raise mental or emotional health as a legal issue.
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, Marcia E. Brubeck may determine that telemedicine is not appropriate and that I require a higher level of care.
I understand that if technical difficulties cause service interruptions during a session, we may need to end and restart the session. If we are unable to reconnect within ten minutes, please call Marcia E. Brubeck at (860) 231-1997 to discuss rescheduling.
I agree to inform Marcia E. Brubeck of my physical address at the start of each session. I understand that, in case of emergency, Marcia E. Brubeck may need to call my identified emergency contact and may also need to contact appropriate authorities.
I agree to permit my healthcare information to be shared with other individuals for the purpose of billing. If my insurance does not cover telemedicine services, I understand that I must pay the full fee directly to Marcia E. Brubeck, LLC.
I have read the information provided above and have discussed it with Marcia E. Brubeck. I understand the information contained in this form, and all of my questions have been answered to my satisfaction.