1. Telehealth Psychological Services
Telehealth Psychological Services allows therapists, clinicians and specialists to provide a diagnosis, consultation and treatment using videoconference technology via telephone or computer.
2. Purpose
The purpose of Telehealth Psychological Services Consent Form is to get permissions from patients in order to participate into telehealth counseling services.
3. Confidentiality
Audio and video recordings of patients during appointments/online visits will be kept private. Medical and personal information of patients are protected by the state and governmental laws.
4. Risks and Benefits
Telehealth Psychological Services aims to provide a complete treatment to patients. It is considered and supported by researches that online counseling is an effective way in treatment of various disorders, personal issues and problems. On the other hand, it may not be beneficial and there is no guarantee that the counseling will be effective for patients.
5. Payment
Patients agree that they are responsible for paying any additional cost or payment that their insurance providers do not cover.
6. Rights
Patients can withdraw and withhold this consent at any time and they can end the treatment any time they would like to. Any action of patients will not affect the future treatment of or accessibility to counseling services.
7. Consent
By signing this form, I agree that I know and understand the information above. My questions were answered completely during the discussion with the therapist, clinician or specialist. I hereby give my consent to participate into telehealth counseling services provided by the healthcare organization.
Emergency Protocols I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life- threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.