TELEHEALTH/TELEMENTAL HEALTH CONSENT
I understand that telemental health (also known as telehealth) is a model of delivering health care services, including psychotherapy, via telecommunication technologies (ex. internet video or phone) to facilitate diagnosis, consultation, treatment, education, and care management. *Although your treatment plan may be for in-person services, due to inclement weather, illness, travel or other conditions impacting yourself or you counselor, the option of video or phone sessions is generally a backup solution and helps support the continuity of your mental health treatment.*
1. I have a right to confidentiality with regard to my treatment and related communications via telehealth under the same laws that protect the confidentiality of my treatment during in-person psychotherapy. The same mandatory and permissive exceptions to confidentiality outlined on the INFORMED CONSENT tab apply to telemental health.
2. I understand that there are risks associated with participating in telehealth including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my therapist, that my psychotherapy sessions and transmission of my treatment information could be disrupted or distorted by technical failures, and/or interrupted or accessed by authorized persons, and that the electronic storage of my treatment information could be accessed by unauthorized persons.
3. I understand that miscommunication between myself and my therapist may occur via telehealth.
4. I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions. This also applies to children in counseling who have the same rights of privacy and being free from distractions. I understand that if my therapist has to cancel the session while it is in progress due to the lack of privacy or distractions and/or intrusions at my location, this may be considered a late cancellation and I may be subject to a late cancel fee.
5. If my sessions are ONLY provided through telehealth, I understand that at the beginning of each telehealth session my therapist is required to verify my full name and current location. If my sessions are a combination of in-person and telehealth, my therapist is required to confirm my identity and my current location.
6. I understand that in some instances telehealth may NOT be as effective or provide the same results as in-person therapy. I understand that if my therapist believes I would be better served by in-person therapy, my therapist will discuss this with me and change our format to in-person or refer me to another therapist who can provide such services.
7. I understand that while telehealth has been found to be effective in treating a wide range of mental and emotional issues, there is no guarantee that telehealth is effective for all individuals. Therefore, I understand that while I may benefit from telehealth, results cannot be guaranteed or assured.
8. I understand that some telehealth platforms allow for video or audio recordings and that neither I nor my therapist may record the sessions without the other party's written permission.
9. For self-pay clients: I have been provided with the price of each session and agree to it. If my price is based on a sliding fee scale, I agree to immediately provide Family Counseling Service with any and all updates to my household income. For insurance clients: I agree that Family Counseling Service will bill my insurance plan for telehealth and that I will be billed for any portion that is the client/patient's responsibility (ex. co-payments).
10. I understand that my therapist will make reasonable efforts to ascertain and provide me with emergency resources in my geographic area. I further understand that my therapist may not be able to assist me in an emergency situation. If I require emergency care, I understand that I may call 911 or proceed to the nearest hospital emergency room for immediate assistance.
I understand that telemental health (also known as telehealth) is a model of delivering health care services, including psychotherapy, via telecommunication technologies (ex. internet video or phone) to facilitate diagnosis, consultation, treatment, education, and care management. *Although your treatment plan may be for in-person services, due to inclement weather, illness, travel or other conditions impacting yourself or you counselor, the option of video or phone sessions is generally a backup solution and helps support the continuity of your mental health treatment.*
1. I have a right to confidentiality with regard to my treatment and related communications via telehealth under the same laws that protect the confidentiality of my treatment during in-person psychotherapy. The same mandatory and permissive exceptions to confidentiality outlined on the INFORMED CONSENT tab apply to telemental health.
2. I understand that there are risks associated with participating in telehealth including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my therapist, that my psychotherapy sessions and transmission of my treatment information could be disrupted or distorted by technical failures, and/or interrupted or accessed by authorized persons, and that the electronic storage of my treatment information could be accessed by unauthorized persons.
3. I understand that miscommunication between myself and my therapist may occur via telehealth.
4. I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions. This also applies to children in counseling who have the same rights of privacy and being free from distractions. I understand that if my therapist has to cancel the session while it is in progress due to the lack of privacy or distractions and/or intrusions at my location, this may be considered a late cancellation and I may be subject to a late cancel fee.
5. If my sessions are ONLY provided through telehealth, I understand that at the beginning of each telehealth session my therapist is required to verify my full name and current location. If my sessions are a combination of in-person and telehealth, my therapist is required to confirm my identity and my current location.
6. I understand that in some instances telehealth may NOT be as effective or provide the same results as in-person therapy. I understand that if my therapist believes I would be better served by in-person therapy, my therapist will discuss this with me and change our format to in-person or refer me to another therapist who can provide such services.
7. I understand that while telehealth has been found to be effective in treating a wide range of mental and emotional issues, there is no guarantee that telehealth is effective for all individuals. Therefore, I understand that while I may benefit from telehealth, results cannot be guaranteed or assured.
8. I understand that some telehealth platforms allow for video or audio recordings and that neither I nor my therapist may record the sessions without the other party's written permission.
9. For self-pay clients: I have been provided with the price of each session and agree to it. If my price is based on a sliding fee scale, I agree to immediately provide Family Counseling Service with any and all updates to my household income. For insurance clients: I agree that Family Counseling Service will bill my insurance plan for telehealth and that I will be billed for any portion that is the client/patient's responsibility (ex. co-payments).
10. I understand that my therapist will make reasonable efforts to ascertain and provide me with emergency resources in my geographic area. I further understand that my therapist may not be able to assist me in an emergency situation. If I require emergency care, I understand that I may call 911 or proceed to the nearest hospital emergency room for immediate assistance.
