I hereby consent to interacting via the internet and/or telephone counseling with Dr. Michelle Watson. I understand that these modes of service include the practice of mental health care delivery, diagnosis, consultation, treatment, transfer of health care data, and I understand that internet and/or telephone counseling also involves the communication of my mental health/health information, both orally and visually, to health care practitioners located in and outside of Oregon.
Specifically, these modes of service delivery involve the provision of treatment services via televideo conferencing or telephonically.
I understand that I have the following rights with respect to internet and/or telephone counseling:
(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or 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 health care information also apply to internet and/or telephone counseling. As such, I understand that the information disclosed by me during the course of my treatment 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 internet and/or telephone counseling interaction to researchers or other entities shall not occur without my written consent.
(3) I understand that there are risks and consequences from internet and/or telephone counseling, 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 health care information could be interrupted by unauthorized persons; and/or the electronic storage of my health care information could be accessed by unauthorized persons.
(4) In addition, I understand that internet and/or telephone counseling-based services and care may or may not be as complete as face-to-face services.
(5) 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 area.
(6) 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 improved, and in some cases may
even get worse. I understand that I may benefit from internet and/or telephone counseling, but that results cannot be guaranteed or assured.
(7) Finally, I understand that I have a right to receive a copy of my records unless my psychotherapist believes that seeing them would be emotionally damaging to me, in which case she will arrange to send them to a mental health professional of my choice. Because of the nature of professional records, they can be misinterpreted and/or upsetting to untrained readers. My psychotherapist recommends that I review them in her presence so that we can discuss the contents. I further understand that I will be charged an appropriate fee for any time spent in preparing information requests.
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.