I hereby consent to engage in telemedicine (e.g., internet or telephone based therapy) with The Resilience Group, Inc. The main venue for my psychotherapy treatment will be the office at the address listed below. I understand that telemedicine includes the practice of health care delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications (including telephone, written, text, email, or video conference, etc). I understand that telemedicine also involves the communication of my medical/ mental health information, both orally and visually, to other health care practitioners.

CLIENT RIGHTS

I understand that I have the following rights with respect to telemedicine:

• I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
• The laws that protect the confidentiality of my medical information also apply to telemedicine. 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. (See also Informed Consents/ HIPAA Notice of Privacy Practices forms, provided to me, for more details of confidentiality and other issues.)
• I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.
• I understand that I have the right to access my medical information and copies of medical records in accordance with Georgia law, that these services may not be covered by insurance and that if there is intentional misrepresentation, therapy will be terminated.

POTENTIAL RISKS

I understand that there are risks and consequences from telemedicine. These may include, but are not limited to:

• The possibility, despite reasonable efforts on the part of my psychotherapist, that the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons; and/or misunderstandings can
  more easily occur, especially when care is delivered in an asynchronous manner.
• Telemedicine based services and care may not yield the same results nor be as complete as face- to-face service.
• If my psychotherapist believes I would be better served by another form of psychotherapeutic service (e.g. face-to-face service), I will be referred to a psychotherapist in my area who can provide such service.
• There are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not improve and in some cases may even get worse.

POTENTIAL BENEFITS

I understand that I may benefit from telemedicine, but results cannot be guaranteed or assured. The benefits of telemedicine may include, but are not limited to:

• Finding a greater ability to express thoughts and emotions.
• Access to the expertise of a specific specialist.
• Transportation and travel difficulties are avoided.
• Time constraints are minimized.
• There may be a greater opportunity to prepare in advance for therapy sessions.

CLIENT UNDERSTANDS AND AGREES TO:

• None of the TeleMental health sessions will be recorded or photographed without my written permission.
• Because this is a technologically based method sometimes it may be necessary for a technician to assist with the equipment. Such technicians will keep any information confidential.
• TeleMental health is done over a secure communication system that is almost impossible for anyone else to access, but that since it is still a possibility, I accept the very rare risk that this could affect confidentiality.
• My therapist has explained to me the video conferencing technology and telephone procedures that will be used. I understand that TeleMental Health sessions will not be exactly the same as an in person session due to the fact that I will not be in the same room as my therapist.
• There are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. My therapist or I can discontinue the TeleMental sessions if it is felt that the videoconferencing or telephone connections are not adequate for the situation.
• My demographic information may be shared with other individuals for scheduling and billing purposes.
• I may experience benefits from the use of TeleMental health in my care, but no results can be guaranteed or assured.
• If there is an emergency during a TeleMental health session, then my therapist will call emergency services and my emergency contacts.
• If the video conferencing or telephone connection drops while I am in a session, I will have a phone line available to contact my therapist.

I have read and I understand all of the information on this form, which has also been explained to me verbally. I have discussed it with my therapist or a representative of The Resilience Group and all of my questions have been answered to my satisfaction.

My signature on this form indicates:

• I have provided a working telephone number to reach me if the video conferencing connection fails during a session. I agree to update The Resilience Group and/or my therapist immediately with any changes to my phone number. I understand that failure to do so could result in TeleMental Health services being terminated.
• My counselor has provided me with a contact number. If connection fails and my therapist does not call me back within 5 minutes, then I will call my therapist. (912) 508-1223
• I have provided two emergency contact numbers and the number to my preferred hospital and local police department with non-emergency phone number. I understand this information is required in order to enter into TeleMental Health services. I am giving my therapist or a representative of The Resilience Group permission to contact my emergency contact and/or the hospital or police department if there is an emergency during a session.
• I created and will adhere to the safety plan below in case of an emergency.
• I hereby give my informed consent for the use of TeleMental health in my care.