TELEHEALTH (VIDEO/PHONE) COUNSELING AGREEMENT
The purpose of this form is to obtain your consent to participate in telehealth, which involves counseling by phone, video, or secure online email portal.
Benefits include:
1. Convenience, since there is no travel time
2. I can see you even if you are unable to get to my office, or when you are sick
3. I can see you when you travel within the state, or even when you move within the state
Limitations/Risks include:
1. There is a greater chance of misunderstanding -- we might not see each other's body language or hear subtle differences in voice tone that could easily be picked up in person
2. If we meet in-person, I have more control of interruptions. With video, I can't control your setting.
3. Internet connections could cease working or become too unstable to use
4. You may feel more emotional distance due to the lack of in-person contact and presence.
5. I cannot guarantee the privacy/confidentiality of conversations held via phone, as these can be intercepted accidentally or intentionally. I cannot guarantee that hackers will not access video calls.
6. I cannot immediately intervene if you are in crisis.
Is it right for you? Telehealth is not a good fit for everyone. If at any point you find the telehealth platform difficult or distracting to use, please let me know. You have the right to discontinue receiving telehealth counseling at any time, without consequence. I am always happy to discuss moving to phone or in-person sessions. Likewise, if at any point I do not feel telehealth is working for me or for your treatment, I may discontinue this treatment option.
Logistics
1. If we are connecting by video, I will send you a link to sign in to my secure and HIPAA-compatible video platform. It is OK to "arrive" early -- I will connect with you at the time of the session. If we are connecting by phone, I will call you at our scheduled time.
2. I will be in a private location where I am alone. You are responsible for your confidentially on your end, and need to be in a private location where you can speak openly without being overheard by others.
3. At the start of the session, I may verify your location (street address). I can only provide therapy to you while you are in the state where I am licensed. If I do not ask, please be sure to tell me if you are not at your home.
4. Do not invite others to join us for any part of the session without discussing this with me in advance.
5. Please be sure to have a cell phone with you or be near a phone in case video gets cut off.
You may have a better experience if you:
1. Use a computer or tablet instead of a cell phone so that you can see me better.
2. Make sure your device is connected to power, or at least fully charged.
3. Wear a two-ear wired headset with microphone (this can help us hear each other)
4. Close other applications or programs on your computer.
5. Make sure you have strong internet connection -- you may need to be near your modem.
6. Consider how you will reduce interruptions (ex. talking to family in advance about your need for privacy during that hour, using a "do not disturb" sign on your door, etc.)
7. Find a location where your face will be well-lit so I can see your facial expressions clearly.
Connection Loss:
1. For video sessions: If we lose our connection during our session, please quit and restart your search engine (or computer), and sign in again. If you can't reconnect, I will call you
2. For phone sessions: If we lose our connection during our session, I will call you again from an alternate number, which may show up as restricted or blocked -- please be sure to pick up the phone. After 5 minutes if you have not heard from me, you may also attempt to call me at my office number (continued)
Security
· I utilize video software and hardware tools that adhere to security best practices and legal standards for the purposes of protecting your privacy.
· It is not recommended that you communicate using a public wireless network.
· You represent that you are not using someone else's device or your employer's computer, since employers have the right to monitor their equipment and networks, which could compromise your privacy.
· It is recommended that you have sufficient firewalls, anti-virus, and malware software.
· You have the sole responsibility for security and privacy of your devices, equipment, and internet connection.
Recording of Sessions:
· No sessions will be recorded by me, and the telehealth platform I use states that there is no recording of the session, no information collected, and no digital record saved afterwards. Please note that recording or screenshots of any kind of any session are not permitted and are grounds for termination of the client-therapist relationship.
Session Cancellations: Phone/video sessions are treated as in-office sessions when it comes to late cancellations and no-shows -- 24-hour advance notice is required, otherwise you will be charged the full session fee (not just a copayment), except for cases of unforeseen medical emergency. Cancellations should be communicated via email and phone.
If you are outside the area that I practice, I will identify emergency resources in your area. If you are in crisis and we get disconnected call 911, go to your local emergency room if you cannot reach me.
Please share with me if you have severe feelings of helplessness, hopelessness, or wanting to hurt yourself or others. There are many steps I can take to help, even at a distance. However, if I have extreme concerns about your safety at any time during a phone session, we may need to have you come to the office, or I may need to call your support system or emergency services to keep you safe.
Please note that everything in our informed consent that you signed, including all the confidentiality exceptions, still applies during phone/video sessions. By signing below, you agree that you have read and understand all of the above. You give permission for me to communicate with your emergency contact if client is concerned about your safety. You agree that you have had the chance to ask questions, that you understand the limitations associated with participating in telehealth sessions and consent to attend sessions under the terms described in this document.