Informed Consent and Fees for Telehealth Services

Informed Consent and Fees for Telehealth Services

Informed Consent for Technology-Assisted Counseling
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Emergency Contact Name and Phone Number. This is required. This person will be contacted if there is any reason to believe you may be in crisis and may need a welfare check, or are observed during your tele-health session to be in medical or mental health crisis:
The purpose of this Informed Consent for Technology Assisted Counseling (telehealth) is to inform you, the client, about your privacy and confidentality, potential risks and benefits, and fees regarding telehealth counseling services, with Lynne A. Santiago PhD, LMHC, the therapist.

Telehealth refers to the use of video conferencing, direct messaging, real time chat, texting, emailing, phone calls.
Privacy and Confidentiality

Maintaining client confidentiality is extremely important. The therapist will take extraordinary care and consideration to prevent unnecessary disclosure.

Information about the client will only be released with his or her permission with the following exceptions:

1) If therapist believes that someone is seriously considering or likely to attempt suicide or engaged in self harm behaviors with out intent to die, but that has potential high risk of serious injury, to include death;

2) the therapist believes that someone intends to assault another person;

3) If therapist believes someone is knowingly engaging or intends to engage in behavior which will expose another person to a potentially life-threatening communicable disease, if that someone declines treatment or risk reduction actions;

4) if therapist suspects abuse, neglect, or exploitation of a minor or incapacitated adult;

5) if therapist believes someone’s mental condition leaves the person gravely disabled.
Risks and Benefits

I understand the potential risks of telemental health, which may include the following:

1) the video connection may not work, or it may stop working during a session; the video or audio transmission may not be clear; there may be technical problems that interupt the session

3) I or my therapist may discontinue the telemental sessions at any time if it is felt that the videoconferencing, text, email, or telephone connections are not adequate for the situation.

4) Though all efforts are made to protect private healthcare information using HIPAA-compliant technology to transmit and receive video and audio and stores all notes and information, there is still a possibility of a breach, and I accept the very rare risk that this could affect confidentiality.

5) It is my responsibility to increase privacy and confidentiality by ensuring that my physical location during videoconferencing is free of other people, that I protect and not share my passwords to computer, websites, phone.

6) I understand that recording my sessions is prohibited.

I recognize the benefits of telemental health, which may include the following:

1) reduced cost and time commitment for treatment due to the elimination of travel;

2) ability to receive psychotherapy when in person, office visits are not possible

3) access to services that are not available in my geographic area.

*** I understand that tele-health is not appropriate for crisis intervention. IF you are in crisis, and require immediate attention please call the 24 hour crisis line at 211, or present to the nearest emergency room.

I give my consent to engage in psychotherapy via videoconferencing, texting, direct messaging, real time messaging, email, phone under the conditions outlined in this document.

I consent to receive appointment reminders by email.
Signature