TelecounselingConsent Form

Telecounseling Consent Form
TELECOUNSELING PATIENT CONSENT

PURPOSE: The purpose of "Telecounseling Consent Form" is to get the client's consent in order to participate in telecommunications counseling appointments.

RECORDS: Telecommunications with clients will not be recorded and/or stored.

TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the client will be discussed during the telecounseling appointment via video and/or audio.

ACCESS: The client accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telecounseling appointment.

PATIENT RIGHTS: The client can withdraw his/her consent at any time and can ask the questions related to telecounseling appointments and technical requirements for telecommunication.
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Type
Guardian Name

First NameLast Name
By signing this form,

I understand that all the laws that are protecting my privacy of medical history or information are also applied to telehealth practices.

I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures.

I understand that I can be charged the additional fees that my insurance does not cover.

I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.
Date

MonthDayYear
Date
Signature

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Telecounseling Consent Form