Consent to Teletherapy
Online Therapy Consent
I understand the following and that I have the following rights with respect to teletherapy:
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.
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.
It is my responsibility to create a confidential environment in which to participate in online therapy. This includes, but is not limited to the following:
a) Using a headset with a microphone to maximize my privacy during sessions.
b) Being in a room with a closed door and closed windows to insure my privacy during sessions.
c) Using private computer equipment for tele-therapy to ensure my privacy during sessions.
d) Taking precautions to protect what I say or what my therapist says from being overheard by another person(s) during sessions.
The therapist is not providing an emergency service, and I have been informed of whom to call in an emergency or during weekend and evening hours.
Conversations with the therapist will be confidential unless prohibited by law, as stated above.
I am financially responsible for this treatment.
I know of no reason(s) that I should not undertake this therapy, and I agree to participate fully and voluntarily.
I have read and received a copy of the HIPAA Notice of Privacy Practices. I have discussed any concerns about the policies with the therapist prior to signing this consent.
I understand that state approved supervisors may review my case with my identity held confidential for the purposes of fulfilling state licensing requirements for my therapist.
I understand that peer-to-peer supervision may be done on a case-by-case basis.
Your decision to enter into therapy was undoubtedly a serious one arrived at after considerable thought. Whether your physician, urged to come by family or friends or have come because of problems and feelings only you know about, referred you the decision to come here was yours.
Therapy is a two-way effort entailing mutual respect, responsibility and consideration between you and your therapist. The policy presented is designed to make your therapy productive and to avoid any misunderstanding regarding the mutuality of the therapeutic process.
As a Marriage and Family Therapist, my area of training is the systemic treatment of individuals, couples, and families. The systemic approach to therapy takes into consideration all immediate family members in family therapy sessions. I, along with you, will decide which family members (if any) need to be included in therapy. Various goals will be established together with you at the outset of therapy.
Therapy naturally involves activities such as identifying emotions and revealing secrets. There may be risks associated with our disclosures to other family members or other family members' disclosures during the course of therapy, as well as exploration of issues. Decisions to disclose will be made by you except where mandated by law. It is expected that some uneasiness or painful emotions may occur, as you are involved in therapy. Discussing painful issues will naturally create discomfort. Your participation in therapy is essential toward helping address your concerns.
The Board of Examiners for the Licensure of Professional Counselors, Marriage and Family Therapists and Psychoeducational Specialists requires that all clients be informed that all forms of dual relationships such as business ventures and sexual intimacy are prohibited.
Please be aware that there is a higher incidence of divorce if only one partner in a relationship is involved in therapy. It is also important that you understand there is no guarantee all of your concerns, issues, or problems will be successfully resolved. I cannot guarantee outcomes. The outcomes may vary from your expectations.
You may discontinue participation in therapy at any time. If you are not satisfied with the course of therapy, please discuss this concern with me.