Existing Client TeleHealth Agreement Form

Informed Consent for Telehealth Services

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By signing below, you affirm to provide the above information to supplement your existing client information at PPCC, Inc.*

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Informed Consent for Telehealth Services
This Consent form does not replace PPCC’s primary Informed Consent Form for “In Office” mental health services you previously signed and consented to; it is in addition to.

The definition of Telehealth involves the use of electronic communications to enable PPCC, INC mental health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, treatment, referral to resources, education, and the transfer of medical and clinical data. I understand:
1. The Florida laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is confidential. I understand during my telehealth sessions my provider will ensure a private and confidential environment and I agree to do the same at my location.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that there are risks and consequences from telehealth, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons.
4. I understand that if my counselor believes I would be better served by another form of intervention than telehealth, I will be referred to a mental health professional that can provide “in-person” services.
5. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.
6. I understand telehealth sessions shall not be recorded in any way by either the practitioner or client.
By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

I have read this document and understand the risks and benefits related to the use of telehealth services. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.

I hereby attest by signature that I have read, understood, and agree to the terms of this document.
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By signing, you agree to the informed consent for telehealth services
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Informed Consent for Telehealth Services

Informed Consent for Telehealth Services