Telehealth Client Informed Consent Form
In addition to our general “Confidentiality and Consent Form”, which includes information about confidentiality and its limits, information storage, informed consent to treatment, and consent to exchange information, we ask that you read and sign this specific Telehealth Consent Form.
If you would like a copy of the original, general Confidentiality and Consent Form, please let us know by contacting reception at firstname.lastname@example.org
By signing this consent form or replying by email, I agree that:
I understand that the benefits of telehealth / video conferencing therapy sessions can
Continued access to my therapist during the COVID-19 pandemic
Continued therapeutic support as part of my treatment plan
Avoiding the need for me to travel to my psychologist and increase the risk of
exposure to myself and others
I also understand that there are potential risks and down sides of telehealth / video conferencing therapy sessions, and that these can include:
Telehealth / video conferencing may not feel the same as a face to face sessions
There could be technical problems that could affect the video / sound quality or
connection, and this may disrupt the session in some ways
Although my psychologist chooses video conferencing software, which has end-toend
encryption and high security standards, there is still a small risk of hacking or
others tapping into the video connection
I understand that my psychologist is taking the necessary precautions to ensure confidentiality including:
Ensuring the privacy of the telehealth session is upheld in the same way an in-person
session would be, by choosing a private location or using headphones
Not allowing any voice or video recording of the session
I have been informed of and understand the payment processes for my telehealth session, and consent to comply with these.
I understand that I can ask questions about the telehealth session at any time.