1. I hereby authorize Jireh Counseling Center, PLLC to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.

2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment may not be started or ended as intended.

3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if technical difficulties, such as internet speed exists.

4. I agree that my behavioral health records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.