I full name hereby consent to engaging in telemental health with Bonner General Behavioral Health.  I understand that "telemental health” includes the practice of healthcare delivery, diagnosis, consultation, treatment, transfer of mental health data, and education using interactive audio, video, or data communications.


Telemental health means the remote delivery of health care services via technology-assisted media. This includes a wide array of clinical services and various forms of technology. The technology includes but is not limited to a telephone, video, internet, a smartphone, tablet, PC desktop system, or other electronic means. The delivery method must be secured by two-way encryption to
be considered secure. Synchronous (at the same time) secure video chatting is the preferred method of service delivery.
 
I understand that elemental health also involves the communication of my medical/mental health information, both orally and visually, to my provider, who may be within Idaho or outside of Idaho at the time of our communication.  I understand that I have the following rights with respect to elemental health:


1)     I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefit to which I would otherwise be entitled. 


2) The laws that protect the confidentiality of my medical
and mental health information also apply to telemental health.  As such, I understand that the information disclosed by me during the course of my therapy is confidential.  However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence towards self and/or an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. 

In case of emergency, my location is: address and contact information for my emergency contact person is:    Name and phone number                 
I understand my therapist may contact my emergency contact and/or appropriate authorities in case of an emergency.