Definition of Services:
This contract indicates consent for distance-oriented consultations or behavioral health sessions, otherwise known as teletherapy, which take place over a HIPPA compliant platform.
Teletherapy has the same purpose or intention as psychotherapy sessions or consultations that are conducted in Dr. Sarah Allen Inc.’s office and as such are charged at the same rate as in-office sessions.
Credit card payment details are submitted prior to the first appointment. Cash/checks cannot be used for teletherapy sessions.
Client’s Rights, Risks, and Responsibilities:
I understand that I have the following rights with respect to teletherapy:
1. I, the client, need to be either a resident of Illinois or Florida.
2. I, the client, have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
3. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is confidential, although all rules regarding mandated reporting and reporting harm to self or others remain the same as office sessions as per my professional ethical standards and legal protocol.
4. I understand that there are risks and consequences of participating in teletherapy, including, but not limited to, the possibility, that despite best efforts to ensure high encryption and secure technology, our session could be disrupted or distorted by technical failures. If there is a loss of connection, I, the client, will initiate the callback, either to try again via Google Meet or Doxy.me video or finish my session by calling 847 791-7722.
5. I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in teletherapy. I am responsible for (1) providing the necessary computer or telecommunications equipment and internet access for my teletherapy sessions, and (2) arranging a location with enough lighting and privacy that is free from distractions or intrusions for my teletherapy
session. It is the responsibility of Dr. Sarah Allen Inc. to do the same on her end.
6. I accept that teletherapy does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support.
Clients who are actively at risk of harm to self or others are not suitable for teletherapy services. If this is the case or becomes the case in future, Dr. Sarah Allen Inc. will recommend more appropriate services.
By signing this contract, I indicate my compliance with the above-stated expectations.
I reserve the right to revoke my consent, in writing, at any time. This consent will be valid for 1 year following the date of signature.