Informed Consent for Telehealth Counseling Services
As a licensed mental health provider I am obliged to inform you that TeleMental health services involve the use of electronic communications (telephone, written, text, email, video conference, etc.) to enable therapists to provide services to individuals who may otherwise not have adequate access to care. TeleMental health may be used for services such as individual, couples, or family therapy, follow-ups, and training/education in a group setting. TeleMental health is a relatively recent approach to delivering care and there are some limitations compared with seeing a therapist in person. These limitations can be addressed and are fairly minor depending on the needs of the client and the care with which the technology (cell phone, computer, etc.) is utilized. It is important that both the client and the counselor be located in a private place during their sessions, and that the security of their technology be up-to-date with appropriate security protection.
Expected TeleMental Health Benefits:
• Improved access to care by enabling individuals to remain in their community
• Access to the expertise of a specific specialist
Possible Risks:
There are potential risks associated with the use of TeleMental health. These risks include, but may not be limited to:
• Information transmitted may not be sufficient (e.g. poor sound or resolution of images) to allow for appropriate treatment such as play therapy
• Delays in treatment could occur due to deficiencies or failures of the equipment
• In very rare instances, security protocols could fail, causing a breach of privacy of personal information. However, security measures will be taken to prevent a breach of privacy
Additional Points for Client Understanding:
1. I understand that TeleMental health services are completely voluntary and that I can choose not to do it or not to answer questions at any time.
2. I understand that none of the TeleMental health sessions will be recorded or photographed without my written permission.
3. I understand that the laws that protect privacy and the confidentiality of client information also apply to TeleMental health, and that no information obtained in the use of TeleMental health, which identifies me will be disclosed to other entities without my consent.
4. I understand that because this is a technologically based method sometimes it may be necessary for a technician to assist with the equipment. Such technicians will keep any information confidential.
5. I understand that TeleMental health is done over a secure communication system that is almost impossible for anyone else to access, but that since it is still a possibility, I accept the very rare risk that this could affect confidentiality.
6. My counselor has explained to me how the video conferencing technology and telephone procedures that will be used. I understand that TeleMental Health sessions will not be exactly the same as an in person session due to the fact that I will not be in the same room as my counselor.
7. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my counselor or myself can discontinue the TeleMental sessions if it is felt that the videoconferencing or telephone connections are not adequate for the situation.
8. I understand that my demographic information may be shared with other individuals for scheduling and billing purposes.
9. I understand that I may experience benefits from the use of TeleMental health in my care, but that no results can be guaranteed or assured.
10. I understand that if there is an emergency during a TeleMental health session, then my counselor will call emergency services and my emergency contacts.
11. I understand that if the video conferencing or telephone connection drops while I am in a session, that I will have a phone line available to contact my counselor.
12. I understand that I will create a safety plan with my counselor in case of an emergency.