Teletherapy Consent Form

On behalf of myself or as a legal guardian of a minor child, I authorize and voluntarily consent to participate in teletherapy provided by a counselor from The Sexual Assault/Spouse Abuse Resource Center (SARC). By choosing this option, I understand that:

1. Teletherapy is the use of interactive audio, video or other telecommunications or electronic media that allows face-to-face communication between a therapist and client.
2. Clinical risks may include discomfort with virtual face to face vs in-person treatment, difficulties interpreting non-verbal communication, and importantly, limited access to immediate resources if risk of self-harm or harm to others becomes apparent.
3. Teletherapy does not provide emergency services. If I am experiencing an emergency situation, 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 Suicide Hotline 1-800-SUICIDE for free 24-hour hotline support.
4. I am responsible for providing the necessary secure computer, telecommunications equipment and internet access for my teletherapy session. I will make arrangements to secure a location with privacy that is free from distractions, intrusions or interruptions during my teletherapy session.
5. Any internet-based communication is not 100% guaranteed to be secure/confidential. The teletherapy system used by SARC Doxy.me meets HIPAA standards for encryption and privacy protection. You will not have to purchase a plan or provide your name when you “join” an online session. Your counselor will provide you with a link to connect to your session. You can just enter your name as “client”. SARC has made every reasonable effort to implement technical security measures that reduce risks of a confidentiality breach. I understand the risk and I agree that SARC and my therapist should not be held responsible if any outside party gains access to our therapy session.
6. The teletherapy session occurs in the state of Maryland and is governed by the laws of Maryland.
7. I understand that technical problems may occur. If a call is disrupted, the therapist will call back unless technical difficulties persist. In such cases, the session can be rescheduled via phone.
8. Due to the pandemic public health crisis of the Coronavirus, Covid-19, it has become possible for treatment delivery to occur via interactive video-conferencing (i.e. virtual “face to face” sessions) in lieu of, “in-person” sessions. Treatment delivery via doxy.me will only be used during this time and in-person sessions will resume when it is safe to do so. In the event teletherapy is not in my best interest, my therapist will explain that to me and suggest alternative options better suited to my needs.
9. My consent to teletherapy can be withdrawn by providing written notification to my therapist. My signature below indicates that I have read this consent form and agree to its terms.
10. If I need support between scheduled therapy sessions, I understand that SARC's 24-hour helpline is available to me at 410-836-8430.
11. Anything you share will remain confidential, unless you disclose abuse or neglect of a child, elder or vulnerable adult, or the intent to harm yourself or others.

For any minor participating in counseling, if there is a custody order in place a copy of the decree must be provided so that the parent's right to consent to treatment can be verified.