1627 N. Swan Rd. STE 101; Tucson, Arizona 85712 

Email: sunlightdesk@gmail.com

Telephone: 520.344.0056

Definition of Telehealth. Telehealth is the use of electronic information and communication technologies by a health care provider to deliver services to an individual/family/couple when they are located at a different site than the provider. Telehealth services are provided via internet technology and may include consultation, treatment, transfer of medical data, emails, telephone conversations, and/or education using interactive audio, video, or data communications.

Purpose. The purpose of this form is to obtain your consent to participate in telehealth services in connection with behavioral health services such as therapy, visitation, and/or assessment.

Benefits and Risks. Telehealth has the same purpose and benefits as services conducted in person. However, due to the nature of the technology use, telehealth services may be experiences somewhat differently than face-to-face treatment sessions/services.

The risks and consequences of participating in telehealth, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my therapist, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; identifying as myself without interactive video; and/or the electronic storage of my medical information could be accessed by unauthorized persons; and my provider not being present in the event of an emergency.

If the provider believes the client would be better served by another form of intervention (e.g., face-to-face services), additional internal options may be explored if possible to accommodate in person sessions now or in the future and/or the client will be referred to a another provider/agency. Despite the client’s efforts and the efforts of the provider, the client’s condition may not improve and, in some cases, may even get worse.

In the event of a technical issue, the provider will make every attempt to work with the client to fix issues from either end. If disconnect occurs, the therapist will try to reinstate the video conferencing and clients are asked to do the same. Should the video call not be able to be reestablished, depending on the time left in the session, the session may transition to phone call for the remainder of the time.

In the event of an emergency, since provider is not physically present, client must provide a list of local emergency contacts.

Confidentiality. SCC purchased GoToMeeting and Vonage, which are both HIPAA compliant.

The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions/service is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; and expressed threats of violence toward an ascertainable victim. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.

However, there are both mandatory and permissive exceptions to confidentiality, which were described at the start of my treatment/service. This exception is any Court Ordered services such as Reunification, Therapeutic Supervised Visits

Setting up the Telehealth environment: Both the provider and the client need to ensure that confidentiality from their environment is secure in that the session cannot be overheard. Client must inform provider of physical location of client during session. Both should ensure that only participants who are expressly invited to the sessions are present and it is only those persons who can overhear the conversation. As with any of our sessions, an additional person must be introduced to the therapist in advance of a session for determination of appropriateness and may not be introduced the same day or during the planned session. Uninvited persons will be asked to leave and/or the session will immediately end and the incident will be documented if this this is not complied with.

Telehealth sessions are strictly structured in conjunction with the agency, the client, and the Telehealth service. As such, there may be back to back appointments with other providers at the agency. It is imperative that sessions start and end on time. Participants should be aware that a full session lasts 45 – 50 minutes and shorter sessions may be prearranged depending on the needs and abilities of the client. The therapist will start and end the sessions in accordance with this.

We would ask that headphones are used to connect to the electronic device on both ends to ensure privacy and increase ability to hear the session. Prepare to have a computer or other appropriate electronic device with internet service be available for the session. Be sure to use the device in the planned room environment in advance of the session to ensure proper connection. Try out a call with someone or listen to a YouTube video in the prepared room to ensure connectivity and auditory capabilities in the prepared room in advance of the call. Make sure there is enough lighting in the environment so faces can be seen, particularly from the front.

Telehealth with Children. SCC asks for parents to help the child get set up in a private room. Prepare the child for anything they may need during the session to prevent/minimize any distraction or disruptions, including using the restroom. Planned sessions with short activities are best. Keep in mind that flexibility is key and that the best laid plans for a session may alter depending on the needs and abilities of the child. It is useful for kids to have a few selected items for the session to share such as dolls, a book, or a game. The therapist may also have items to share on their end that are related to the specific treatment goals. If sessions are held with a child and a parent at two different locations, it can be helpful for the parent to prepare activities or have toys/books they would like to share with their child. Persons on both ends should be attentive to the session and not engaged in other activities or walking around. This includes but is not limited to not having other electronic devices present for the session such as a TV or a phone.

With younger children or for children with disabilities, it is advised to keep the sessions shorter. They may need an adult to assist them on the child end. This should be pre-discussed with the therapist and all persons involved should be made aware of the presence of the other adult who will be present for the session. The adult should be prepared to do things such as pointing at the screen, encouraging the child to engage or talk, be positive and appropriate, be attentive, and is not to directly engage in directing the other parent or how the time is spent. At times, the supportive parent may be asked about ways they know their child likes to be engaged and/or to assist with this process. The therapist is there to assist with these sorts of communications and instructions as needed.

Telehealth for TSV/SV Services. Participation by phone or video of those named on the Order is allowed with 48 hours advanced notice. Video options must adhere to HIPAA standards. There are different variations to the video call, all of which are at the discretion of the visit supervisor.

SCC asks that the child is given privacy for their call with the visiting parent. Any recordings of the visit by either parent are grounds for termination from services. Adding additional people to a call who are not on the Order, either at the same location or via conferencing is prohibited. Doing so will result in immediate termination of the visit and/or termination of services.

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 benefits to which I would otherwise be entitled.

I accept that teletherapy does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support. I may also contact The Crisis Response Network (CRN) also offers a 24 hour crisis line, 7 days per week: 520.622.6000 or https://www.crisisnetwork.org/crnsa/. Clients who are actively atrisk of harm to self or others are not suitable for teletherapy services. If this is the case or becomes the case in future, my providerwill recommend more appropriate services. I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in teletherapy. I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session. It is the responsibility of my provider to do the same on their end.

Payment for services: Payment is due in full at the time of service.

Consent: By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio/video/computerbased services. If I am in crisis or in an emergency, I should immediately call 91 or seek help from a hospital or crisisoriented health care facility in my immediate area.

I have read and understand the information provided above regarding telehealth, have discussed it with my provider, and all of my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding my service.

I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.

By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.