This form outlines important information about participating in teletherapy or telepsychiatry (telepsych) services with Beacon of Hope. It supplements the Disclosure Statement and Informed Consent for Services you received at the start of care. Please review the following carefully and feel free to ask any questions before signing.
Eligibility and Scope:
This consent applies only to clients physically located in the State of Ohio who receive psychotherapy or medication management services from a provider licensed and located in Ohio.
1. Benefits and Risks of Teletherapy
Teletherapy involves the use of secure video conferencing or telephone services to conduct psychotherapy or medication management remotely. Benefits may include:
- Greater accessibility to care
- Continuity of services despite travel, relocation, or health concerns
- Increased convenience and flexibility
However, teletherapy is different from in-person care and may carry certain risks:
- Difficulty reading non-verbal cues
- Potential limitations in emergency response
- Possible loss of therapeutic connection or effectiveness
2. Confidentiality:
We make every effort to protect your privacy and confidentiality during teletherapy. However, the use of electronic communication introduces certain risks:
- Unauthorized access to transmitted or stored data
- Technology failures or security breaches
- The possibility that someone else in your physical environment may overhear or view sessions
You are responsible for ensuring your sessions are conducted in a private and secure setting where others cannot see or hear the conversation.
The confidentiality guidelines and exceptions described in your general Informed Consent (e.g., risks of harm to self or others, child or elder abuse, court orders, etc.) still apply to all telehealth sessions.
3. Technology Considerations:
You will need access to a secure internet connection, a private space, and a compatible device with audio and video capabilities. You are responsible for:
- Meeting the technical requirements for participation
- Any costs associated with internet access, equipment, or applications
- Notifying your provider of any technological difficulties
We do not record teletherapy sessions, and you must obtain prior written consent before doing so. You must also inform your provider if any third party is present or able to hear or view the session.
4. Platform and Communication:
Beacon of Hope utilizes secure platforms in accordance with HIPAA, the American Counseling Association's Code of Ethics, and applicable Ohio laws. Communication between sessions should occur via the patient portal, which is our most secure and efficient method.
Non-emergent communication may include:
- Medication or symptom questions
- Appointment scheduling
- Billing inquiries
Do not use email or text for emergencies. If this is urgent, please call our office at (513) 516-9293. If it is a life-threatening emergency, call 911 immediately.
5. Emergency Planning:
Because teletherapy limits a provider’s ability to respond to emergencies:
- At the start of each session, you will be asked to confirm your current location and provide the name and contact information of an emergency contact nearby.
- If a crisis arises during a session, your provider may contact emergency services and/or your listed emergency contact to ensure your safety.
If a session is interrupted due to a technology failure:
- If you are in immediate danger, do not wait - call 911 or go to the nearest emergency room.
- If it is not an emergency, wait two (2) minutes. Your provider will attempt to reconnect via the chosen platform.
- If you do not receive a call back within two (2) minutes, please call the office at (513) 516-9293.
6. Crisis and Appropriateness:
Teletherapy may not be appropriate for patients experiencing an active crisis or severe mental health symptoms requiring in-person intervention. If your provider determines at any time that teletherapy is no longer appropriate for your care, we will:
- Transition you to in-person sessions, if possible
- Refer you to a provider in your local area
- Collaborate on a revised treatment plan
7. Fees and Insurance:
- Teletherapy and telepsychiatry sessions are billed at the same rate as in-person services.
- If your insurance or HSA/FSA plan does not cover telehealth, you will be responsible for the full cost of the session.
8. Informed Consent:
By signing below, you acknowledge that you:
- Have read, understood, and agreed to the terms and conditions of this Teletherapy Informed Consent
- Understand the risks and benefits of engaging in teletherapy or telepsychiatry
- Understand the security precautions and technological requirements
- Have received information about emergency protocols
- Understand that this consent is a supplement to the general informed consent you previously signed