Telehealth is a mode of delivering health care services, including psychotherapy, via communication technologies (e.g., Internet or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a client’s health care.

By signing this form, I understand and agree to the following:

1. I have a right to confidentiality with regard to my treatment and related communications via Telehealth under the same laws that protect the confidentiality of my treatment information during in-person psychotherapy. The same mandatory and permissive exceptions to confidentiality outlined in the Informed Consent Form I received from my therapist also apply to my Telehealth services.

2. I understand that there are risks and consequences associated with Telehealth including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my therapist, that my psychotherapy sessions and transmission of my treatment information could be disrupted or distorted by technical failures and/or interrupted or accessed by unauthorized persons, and that the electronic storage of my treatment information could be accessed by unauthorized persons.

3. I understand that miscommunication between me and my therapist may more easily occur via Telehealth.

4. I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions.

5. I understand that at the beginning of each Telehealth session my therapist is required to verify my full name and current location.

6. I understand that in some instances Telehealth may not be as effective or provide the same results as in-person therapy. I understand that if my therapist believes I would be better served by another form of therapy, my therapist will discuss this with me, and I will be referred to a therapist in my area who can provide in-person services as needed. If such services are not possible because of distance or hardship, I will be referred to other therapists who can provide such services.

7. I understand that I may benefit from Telehealth sessions, but that results cannot be guaranteed or assured. I may find that the benefits of Telehealth include but are not limited to: (a) greater ability to express thoughts and emotions; (b) reduced transportation difficulties; (c) minimized time constraints; and (d) a greater opportunity to prepare, in advance, for the therapy sessions.

8. I understand that some Telehealth platforms allow for video or audio recordings and that neither I nor my therapist may record the sessions without the other party’s written permission.

9. I have discussed the fees charged for Telehealth with my therapist and agree to them, and I have been provided with this information in the Informed Consent Form.

10. I understand that my therapist will make reasonable efforts to ascertain and provide me with emergency resources in my geographic area. I further understand that my therapist may not be able to assist me in an emergency situation. If I require emergency care, I understand that I may call 911 or proceed to the nearest hospital emergency room for immediate assistance.

 

CONSENT TO USE THE TELEHEALTH BY THERA-LINK SERVICE

Telehealth by thera-LINK is the technology service we will use to conduct telehealth videoconferencing appointments. By signing this document, I acknowledge:

1. Telehealth by thera-LINK is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither thera-LINK nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

3. The Telehealth by thera-LINK Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care

4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by thera-LINK Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by thera-LINK Service.

5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

 

By signing this form, I certify that:

• I have read or had this form read and/or had this form explained to me.

• I have discussed it with my therapist.

• I fully understand its contents, including the risks and benefits.

• I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

 

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.