Love Counseling Center (LCC) provides telemental health services through secure video and/or phone
sessions.
By signing below, you consent to receive telehealth services as part of your psychotherapy treatment.
This means that your health information may be transmitted electronically between you and your
provider.
You understand and agree to the following:
• You may withdraw consent at any time without affecting your right to future care.
• Benefits include convenience, accessibility, and flexibility of care.
• Risks include technology failures, potential confidentiality breaches, and limitations in emergency
response.
• No guarantee of results is made.
• Sessions will not be recorded without prior written consent.
• Confidentiality is protected under HIPAA, with exceptions required by law.
• In emergencies, appropriate contacts or authorities may be notified.
• Telehealth may not be appropriate for all situations, and higher levels of care may be recommended.
• Technical issues may interrupt sessions; if disconnected, reconnection will be attempted.
• You may request in-person services at any time.
By signing below, you acknowledge that you have read, understood, and agree to this consent.