Consent for Telehealth
Effective: 3/16/2020
Revised: 5/24/2023
While you are attending services with Phoenix Counseling Center, there may be times when services will be delivered via telehealth (interactive video conferencing) in lieu of or in addition to “in-person” sessions. The video conferencing service that we use is Zoom (www.zoom.com), which meets the HIPAA standards of encryption and privacy protection.
Risks may include, but are not limited to, technology dropping due to internet connections, delays due to connections or other technologies, or a breach of information that is beyond our control. Clinical risks such as discomfort with virtual face to face versus in-person services, difficulties interpreting non-verbal communication, and importantly, limited access to immediate resources if risk of self-harm or risk to others becomes apparent. You should discuss with and any other concerns with your counselor before using telehealth. By signing this document, you are stating that you are aware your counselor may contact necessary authorities in case of an emergency. You are also acknowledging that if you believe there is imminent danger to yourself or others you will seek immediate care through your own health care provider, hospital emergency department, or by calling 911. If you join from a location other than the address we have on file for you, you must inform your clinician of your current location.
If we schedule telehealth sessions with you, all of the agreements you have previously consented to when you enrolled in services are still in effect. This includes, but is not limited to, fees and payments, attendance and cancellation policies. Mandatory reporting laws regarding child, elder, and dependent adult abuse, and any threats of violence will be reported to appropriate authorities. All HIPAA confidentiality laws will be adhered to. Further, I understand that the dissemination of any personally identifiable images or information from the telehealth interaction to any other entities shall not occur without written permission. I will never attempt to capture of disseminate images of other participants (i.e. while attending group sessions).
When participating in sessions via telehealth, I will provide a quiet, interruption-free environment where I can reasonably assure my own privacy and confidentiality, as well as that of other participants (if attending telehealth groups). I may be asked to prove this by showing the environment to ensure privacy.
I have read and agree to the above terms.