I consent for   First Name     Last Name   to engage in telehealth services with Family Tree Clinic. I understand and agree to the following for the duration of telehealth services with Family Tree Clinic:

1. I have the right to withhold or remove consent for telehealth services at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.
2. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information released by me during the course of my sessions is confidential, just as it would be if I were in the clinic. I understand that mandated reporting laws will be followed by my provider during telehealth visits.
3. I understand that telehealth visits are transmitted via HIPAA approved platforms and that providers will take all reasonable measures to ensure that privacy is maintained during telehealth appointments. It is my responsibility to ensure that I access the internet through secure means and that I am in a private location to conduct my session to maintain privacy.
4. I understand that certain situations including emergencies and crises are inappropriate for telehealth services. If I am in crisis or in an emergency, I should immediately call 911 or go to the nearest hospital or crisis facility. The provider may not be able to provider medical treatment using interactive electronic equipment nor provider or arrange for emergency care that you may require.
5. I understand that there are risks and consequences from telehealth, including but not limited to, the possibility, despite reasonable efforts on the part of my provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
6. I understand that telehealth based services and care may not be as complete as face-to-face services and that not all therapeutic interventions, services or patients are appropriate for telehealth services. I also understand that if my provider believes I would be better served by another form of services (e.g. face-to-face services) I will be asked to physically come to Family Tree Clinic for a face-to-face visit or referred to a provider who can provide such services in my area.
7. I understand that a lack of access to all the information that might be available in a face-to-face visit, but not in a telehealth session, may result in errors of judgment. Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.
8. I understand that a limited examination may take place during the videoconference and that lab and other tests are not available via telehealth.