TELEMEDICINE INFORMED CONSENT
I hereby consent to engaging in telemedicine with Shawna Young,LMFT as part of my psychotherapy. I understand that "telemedicine" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located in Indiana or outside of Indiana. I understand that Shawna Young, LMFT is licensed by the state of Indiana, and I attest that I am a resident of the state of Indiana.
I understand that I have the following rights with respect to telemedicine:
1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment; nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
2. The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.
I am aware that a “HIPPA Notice of Privacy” is available for me to read and print in the Forms section at: www.queenofheartscounseling.com
3. I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, 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. A significant number of steps are taken to ensure the confidentiality and privacy of Online communication(s) between you and your online counselor, these actions, in whole or in part, cannot guarantee the security of Internet transmissions. I permanently agree to release and indemnify Shawna Young, LMFT and/or Queen of Hearts Counseling from all suits, claims, and other actions originating from psychotherapy provided.
In addition, I understand that telemedicine based services and care may not be as complete as face-to-face services. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a psychotherapist who can provide such services in my area.
I understand that online therapy is technical in nature and that problems with the Internet may occur. If something beyond our control disrupts the connectivity of our session I will immediately try to video call the therapist again. If video call is repeatedly unsuccessful for 10 minutes, sessions will be:
1) completed via phone call to the therapist at (317) 912-0149
2) the remaining minutes of the session will be rescheduled
Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not be improve, and in some cases may even get worse.
4. I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.
5. I understand that I have a right to access my medical information and copies of medical records in accordance with Indiana law.
6. I understand that the fee agreed upon by Shawna Young,LMFT and I is due the day before our session paid via PayPal. If fee is not paid in advance the session may be cancelled. Although PayPal takes extra security measures to encrypt its data, I realize that PayPal is a separate company and I release Shawna Young and Queen of Hearts Counseling of all liability in the event that PayPal mishandles this payment information in any way. I also acknowledge that PayPal will only be used by this Shawna Young, LMFT to accept debit and/or credit card information for payment purposes only.
I agree to give a 24 hour cancellation notice to my therapist in order not to be billed for the session. I also understand that a refund will not be given for any sessions where I fail to attend without notice.
I have read and understand the information provided above. I have discussed it with my psychotherapist, and all of my questions have been answered to my satisfaction.
My electronic signature below attests that I agree to the terms above.