Telebehavioral Health Counseling/Psychiatric Treatment Informed Consent

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.

Client Communication It is the clients responsibility to maintain privacy on their end of communication. Insurance companies, those authorized by the client, and those permitted by law may also have access to records or communications. The client

is encouraged to take precautions to ensure a private space for their use during their telebehavioral health session.

Fees All fees agreed upon for in-person behavioral health counseling or medication management will remain the same for telebehavioral health counseling and/or medication management.

Laws & Standards The laws and professional standards that apply to in-person behavioral services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.

Confidentiality All existing confidentiality protections under federal and Ohio law apply to information used or disclosed during your telebehavioral health counseling session. The client understands that, under the law, and regardless of what form of communication is used in working with practitioner, the practitioner may be required to report to the authorities information suggestion that the client has engaged in behaviors that endanger them or others.

Client Rights I have read this document carefully and fully understand the benefits and risks. I have had the opportunity to ask any questions that I have and have received satisfactory answers. With this knowledge, I voluntarily consent to participate in the telebehavioral health counseling services, including but not limited to any care, treatment, and

services deemed necessary and advisable, under the terms described herein.

Consent to Treat a Minor (if applicable) The above release is given on the behalf of (name of minor) a minor or has been determined unable to be given medical consent.

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