Telehealth Informed Consent

Describes your rights and responsibilites

Read carefully before signing

WHAT IS TELEHEALTH?

"Telehealth" may include therapeutic or non-therapeutic services such as assessment, consultation, individual or group counseling, individual or group psychoeducation, case management or other support services.

Telehealth services occur primarily through interactive telephone or video conference technology, such as Zoom or Google Meet.

Telehealth services delivered by a Therapist are required by law to take place within the state in which the Provider is licensed, with the exception of crisis consultations or sessions, and may not be provided in international jurisdictions. If I am physically located outside of the state in which my Therapist is licensed, I will immediately notify my Therapist.

 

WHAT ARE MY RIGHTS IN REGARDS TO TELEHEALTH SERVICES?

I have the right to withhold or withdraw consent at any time.

The laws that protect the confidentiality of my personal information in a face-to-face counseling setting also apply to Telemental Health services. As such, the information disclosed by me during the course of my sessions is generally confidential. The dissemination of any personally identifiable images or information from the teletherapy interaction to other entities shall not occur without my written consent except in the case of mandatory or permissive exceptions to confidentiality. Such exceptions include, but are not limited to:

• suspected child, elder, and/or dependent adult abuse;
• expressed threat of violence towards an ascertainable victim;
• expressed threat to harm or kill self;
• and court subpoena.

I have a right to access my personal information and copies of case records in accordance with Federal and Florida law. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, it is recommended that you initially review them with your Therapist or have them forwarded to another mental health professional to discuss the contents. 

I agree not to record Telemental Health sessions.

Additional rights:

• You also have the right to expect that your therapist will maintain professional
  and ethical boundaries by not entering into other personal, financial, or
  professional relationships with you.
• If you are unhappy with what is happening in therapy, the hope is that you will talk with your Therapist so that they can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request to be referred you to another therapist.
• You have the right to considerate, safe and respectful care, without
  discrimination as to race, ethnicity, color, gender, sexual orientation, age,
  religion, or national origin.
• You have the right to ask questions about any aspects of therapy and about your Therapist's specific training and experience.

WHEN ARE TELEHEALTH SERVICES NOT APPROPRIATE?

Receiving Telehealth services may not be advised if I have experienced any of the following:

• recent suicide attempt(s),
• psychiatric hospitalization, or psychotic processing (last 3 years)
• moderate to severe major depression or bipolar disorder symptoms
• moderate to severe alcohol or drug abuse
• severe eating disorders
• repeated "acute" crises (e.g., occurring once a month or more frequently)

I agree that certain situations, including emergencies and mental health crises, are inappropriate for remote counseling services. These include:

• thoughts of hurting or killing myself or another person;
• hallucinations;
• being in a life threatening or emergency of any kind;
• having uncontrollable emotional reactions; and/or
• being under the influence of alcohol or drugs.

I understand that my Telehealth Provider may not be available for contact between scheduled sessions.

If I am in an emergency or crisis situation (such as those listed above), I should immediately call 911 or seek help from a hospital or crisis- oriented health care facility in my immediate area.

If I am experiencing thoughts of suicide without a clear commitment to safety, I am to contact one of the following resources:

• 9-1-1
• National Suicide Prevention Hotline: Call 9-8-8
• Crisis Text Line: Text HOME to 741741
• Trevor Project 24 her Crisis Line for LGBTQ+ Youth 866-488-7386
• National Domestic Violence Hotline: 800-799-7233 or text to 88788

There are risks and consequences from Telehealth services, including, but not limited to, the possibility, despite reasonable efforts on the part of the Provider, that:

• the transmission of my personal information could be disrupted or distorted by technical failures;
• the transmission of my personal information could be interrupted by unauthorized persons; and/or
• the electronic storage of my personal information could be accessed by unauthorized persons.

Telehealth services may not be as complete as face-to-face services - additional research is needed on the long-term effects of counseling services via teletherapy versus face-to-face treatment in order to better understand the benefits and limitations of teletherapy treatment. If my Provider believes I would be better served by another form of intervention (e.g. face-to-face services), I will be referred to a mental health professional who can provide such services in my area. 

While I may benefit from Telehealth services, results cannot be guaranteed or assured. There are potential risks and benefits associated with any form of counseling and despite my efforts and the efforts of my Provider, my condition may not improve, and in some cases may even get worse.

 

WHAT IS THE ROLE OF COLLABORATORS?

My consent to Telehealth services includes the identification of two local (or on-site) collaborators. A collaborator is someone I know and trust and who would be a contact person that can be reached by the Telehealth provider if there is any concern for my physical or emotional wellbeing. Such collaborators may be called upon to contact me or to alert local authorities in an emergency situation.

The collaborators that I identify for this purpose, with accompanying consent for Telemental Health Provider to contact one or both of these collaborators if indicated for my safety and wellbeing, are as follows:

I have read and understand the information provided above.

By submitting this form, it signifies my consent to engage in Telehealth Services with Kelly Patrick, LMHC and/or A Kind Place, LLC in accordance with the above expectations and guidelines.

By submitting this form, I agree to follow these guidelines for Telehealth Services.