TELETHERAPY SERVICES

I understand that I have the following rights and responsibilities with respect to teletherapy services:

• Teletherapy services are only offered for COVID-related reasons. Meaning, if you were exposed to someone that tested positive, you're having COVID-related symptoms, you have tested positive, or you simply do not feel comfortable coming for in-person sessions.
• I understand that online psychotherapy services include, but are not limited to, consultation, treatment, and using interactive audio, video, or data communications. I understand that online psychotherapy services involve the communication of my medical/mental information, both orally and visually.
• I understand that teletherapy will not be offered in the following scenarios…and these are not exhaustive:
  • if you are running late for session
  • you overlooked your appointment and did not realize until the last minute
  • you got stuck in a meeting or in traffic
  • you woke up late
  • must receive a package at your home during a designated period
  • waiting for repair person to arrive to repair something in your home
• I understand that in these cases, we will have to reschedule. This may result in a late cancellation fee of $50 if I am unable to be seen the same week.

• I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.

• The laws that protect the confidentiality of my medical information also apply to online psychotherapy services. As such, I understand that the information disclosed by me during the course of my therapy 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 understand that our teletherapy occurs in the state of Indiana, (USA), and is governed by the laws of that state. In a manner of speaking, I am using this modality to visit my therapist’s Indiana office.
• I understand that the dissemination of any personally identifiable images or information from the online psychotherapy services to researchers or other entities shall not occur without my written consent.
• I understand that there are risks and consequences from these services. The online platform used for teletherapy, doxy.me complies with HIPAA and HITECH requirements. However, there is the possibility that, despite my therapist’s reasonable efforts, the transmission of my medical information could be disrupted or distorted by technical failures.
• I understand that on my end of the teletherapy transmission I am responsible for:
  • Providing the necessary computer, telecommunications equipment, and internet access for my teletherapy
  • Securing information on my computer using a password protected, secure internet connection (not public or unsecured Wi-Fi)
  • Having installed and updated an antivirus/anti-malware protection
  • Arranging a location with sufficient lighting and privacy that is free from distractions or intrusions during my teletherapy session.
• I understand that online psychotherapy services may not be as complete as face-to-face services. I accept the distinction made using teletherapy vs. face-to-face psychotherapy. I also accept that teletherapy cannot provide emergency services. During our first session, my therapist and I will discuss an emergency response plan. You can also find this in the Informed Consent for NorthStar Psychological + Consultation Services, LLC. I am aware of the nearest hospital and emergency numbers in my area.
• I understand that there are potential risks and benefits associated with any form of psychotherapy services, and that despite my efforts and the efforts of the therapist, my condition may not be improve, and in some cases may even get worse. I understand that I may benefit from online psychotherapy services, but that results cannot be guaranteed or assured.
• I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law.

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.