Telehealth is the use of two-way secure audio-visual electronic communications or other means to enable a healthcare provider and a patient at different locations to communicate. Services provided via telehealth at Trivium New England Mental Health (TIMH) include appointments for psychotherapy and medication management.

By agreeing to participate in telehealth services, I understand that:

• There are potential risks to using telehealth technology, including but not limited to interruptions, unauthorized access, and technical difficulties.
• Electronic communication is not to be used for any emergency or crisis communications.
• It is my obligation to notify my provider of my location at the beginning of each treatment session. If for some reason, I change locations during the session, it is my obligation to notify my provider of the change in location.
• It is my obligation to notify my provider of any other persons in the location, either on or off camera and who can hear or see the session. I understand that I am responsible for ensuring privacy at my location. I will notify my provider at the outset of each session and am aware that confidential information may be discussed.
• I may not record, either through audio or video, any of the sessions.
• I am responsible for information security on my device, including but not limited to, computer, tablet, or phone.
• Zoom is the technology service used to conduct telehealth videoconferencing appointments. Prior to each session, I will receive an email link to enter the "waiting room" until the session begins. There are no passwords or logins required.

By signing this document, I acknowledge:

1. Telehealth is NOT an emergency service. In the event of an emergency, I will call 911 and/or contact other appropriate emergency contacts.
2. My provider may need to notify emergency personnel in the event they feel there is a safety concern, including but not limited to, a risk to self/others, or my provider is concerned that immediate medical attention is needed.
3. The same fee rates apply for telehealth as apply for in-person treatment. Insurance or other managed care providers may not cover telehealth sessions. I understand that if my insurance, HMO, third-party payor, or other managed care provider do not cover the telehealth sessions, I will be solely responsible for the entire fee of the session.
4. I will not share my telehealth appointment link or information with anyone not authorized to attend the session.
5. I or my provider can discontinue telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me.

I have read and understand the information provided above regarding telehealth, and I hereby give informed consent to the use of telehealth.

Additional Information: