Purpose The purpose of this form is to obtain your consent for the use of telebehavioral health as a modality to providing counseling services and/or medication management with Julia Burrow and Associates, LLC.
Nature of Telebehavioral Health Telebehavioral health is the delivery of behavioral health services using interactive technologies (use of audio, video or other electronic communications) between a practitioner and a client/patient who are not in the same physical location. The interactive technologies used in telebehavioral health incorporate network and software security protocols to protect the confidentiality of client/patient information transmitted via any electronic channel. These
protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.
Risks, Benefits, and Alternatives This service is provided by technology (including but not limited to video, phone, text, apps, and email) and may not
involve direct face-to-face communication. There are benefits and limitations to this service. These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.
Exchange of Information The exchange of information will not be direct and any paperwork exchanged will likely be provided through electronic means or though postal delivery.
I may decline any telebehavioral health services at any time without jeopardizing my access to future care, services, and benefits.
Modification Plan My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the
use of the technologies we have agreed upon today, and modify our plan as needed.
Emergency Protocol In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means. This includes phone call, text, or a different video platforms.