Tele-health consent (Gemini Counseling)

By signing this document I

Name

First NameLast Name

confirm that I understand and agree with all the following points:

1. The following information is provided to clients who are seeking Tele-Mental Health therapy which means the remote delivering of health care services via technology-assisted media. This includes a wide array of clinical services and various forms of technology such as (but is not limited to) video, internet, smartphones, tablet, PC desktop system or other electronic means.*

I understand.

2. Aurolina Valdés (henceforth referred as “the therapist”) utilizes either the applications Doxy.me or Telehealth by Simple Practice to provide video based services. The decision of using one or the other can change on each session depending on the quality of the video call or the technology available to either of us at the moment. The software, applications, programs and procedures utilized are secured by two-way encryption and comply with HIPAA rules, and LMFT licensure laws in the state of Texas and Florida and the ethical guidelines of the Association of Marriage and Family Therapy that are in force at the time of our sessions. This means that every precaution has been taken to provide quality mental health care, protect my information and the confidentiality of our calls.*

I understand.

3. Tele-health services are provided at no extra cost than the one agreed to with Aurolina Valdes, however, I understand that if I take the call using my cellular's phone data plan and I do not have unlimited data my phone company (carrier) could charge me for that usage and I am responsible to pay for those charges.*

I understand that I am solely responsible to pay my cellular's phone data plan and that, if I do not have unlimited data, my phone company (carrier) could bill me substantial extra charges.

4. I (the client) will not be required to purchase any equipment or buy any software or application. Aurolina Valdes will guide me if I need to download the free cellphone application for Telehealth by Simple Practice.*

I agree.

5. NONE of our conversations will be recorded unless the therapist and I agree in advance and I express my consent in writing ahead of time. I (the client) agree NOT to record any of our conversations since the therapist cannot be responsible for the confidentiality of our sessions having no control or information about how those recordings are saved or distributed.*

I (client) agree NOT to record any of our sessions.

6. These are some of the Advantages of Tele Mental Health Services:

6a. Flexibility of schedule. We will agree in advance of date and time for our session but there will be certain flexibility to schedule beyond traditional “office hours”.*

I agree.

6b. Convenience. No traveling to the therapist office. As a client I can chose the location most convenient for me as long as it is a private, quiet place where other people can not hear our confidential conversations.*

I agree.

6c. If I ever need an urgent appointment Aurolina will try to schedule it within the next 48 hrs.*

I agree

6d. Video calls are scheduled to last between 50 minutes to 1 hr., however if there is someone at home or I can have no privacy, Aurolina and I might choose to end the call early and reschedule to make sure my conversations with her are always private. We may or may not adjust the price of a session that was terminated early because Aurolina reserved that time for me.*

I agree

7. The following are some of the Limitations of Tele Mental Health Therapy Services:

7a. There may be a disruption to the service (e.g. phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of personal interaction.*

I understand.

7b. There is a risk of misunderstanding one another when communication lacks visual or auditory cues. For example, if video quality is lacking for some reason, I might not see various details such as facial expressions. Or if audio quality is lacking, I might not hear differences in your tone of voice that I could easily pick up if you were in my office.*

I understand.

7c. The therapy office decreases the likelihood of interruptions. As I client I will try to minimize phone interruptions as well as other people coming into my location.*

I understand.

7d. As the therapist, Aurolina will take every precaution to minimize interruptions and maximize privacy.*

I understand

7e. If something occurs to prevent or disrupt any scheduled appointment due to technical complications there is a possibility we might need to reschedule.*

I understand.

8. Therapist responsibilities:

a. The therapist will comply with all current and active laws and regulations covering Tele-Mental Health services.

b. The therapist is required by law to confirm at the start of every video session my identity and location.

c. Aurolina Valdés is licensed as a Family Therapist in the states of TX and FL therefore I (client) can be located in any of those 2 states. If I (client) am located in any other state or jurisdiction the therapist will have to review the laws on such location to inform me if it is possible for us to plan a session.

d. As a licensed therapist Aurolina Valdes is mandated to keep written records of every session describing in clinical terms the overall sense of the session and other meaningful clinical details. This records are kept in a HIPAA compliant system called Simple Pratice. The records will be stored for a minimum of 5 years for adult clients and a minimum of 5 years after the age of 18 for minor clients as per the laws of TX and FL.

e. The therapist will be available at 817-608-6825 in case our video sessions is dropped.

I understand Aurolina Valdes' responsibilities.*

I do

9. Client Responsibilities::

9a. If I intend to take a call from any other place than the states of Texas or Florida I will inform the therapist several weeks in advance so we can make sure we comply with the laws in such place before initiating a video call. Because of national regulations there will be many circumstances in which Aurolina will not be able to provide telehelath services to me if I am in a state other that Texas and Florida*

I understand.

9b. I am responsible for accessing a Wi-Fi connection (for best call quality and to minimize disruption). I understand that I am responsible for the cost of internet services, Wi-FI on my side.*

I understand.

9c. I understand that it is not recommended to take a voice call over cellular data, however, If I decide to do it I am responsible for any charges or overdrafts to my cellular bill.*

I accept

9d. I agree to take full responsibility for the security of any communications or treatment on my own computer or electronic device and in my own physical location..

I acceptType option 2Type option 3Type option 4

9e. I (the client) am responsible for finding a private, quiet location where the sessions may be conducted and that others cannot hear my conversations. Sessions are not able to take place if other individuals are present in my location*

i accept

9f. If anyone enters the room in which I (client) am located it is my responsibility to informa Aurolina Valdes so that she can pause until we have privacy again.*

I understand

9g. If there are small children around (too young to understand our conversations) I will be responsible of keeping them under my supervision, watching them at all times during our session.*

I accept.

9h. If there are children around that DO understand our conversations I (client) will be responsible for keeping them in a safe space, maybe with another adult in a different room or maybe nearby where I can see them but with earphones so they can not hear me.*

I accept

9i. I will only used email or text to confirm, cancel, postpone our sessions. I will not use it as an alternative means of therapy since it is not confidential*

I understand sending a text is not confidential and I will only use it to schedule or cancel appointments.

10. Suggestions from Aurolina Valdes

a. I suggest that if there are other people in the house you use earphones or a headset so that only "your side" of the conversation can be heard by others.

b. I strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g. has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.).

c. Do not use “auto-remember” names and passwords.

d. Consider using a “do not disturb” sign/note on the door.

e. Please make sure you have a phone with you and that I have that phone number in case have to call you due to technical problems.

11. EMERGENCY MANAGEMENT PLAN. The therapist can usually return a call or message within 24 hours.

If Aurolina is unavailable in the event of an emergency, I am aware that the plan is:

11a. Call the national Suicide Prevention Line 1-800-273-8255*

I am aware that I can save this number on my cell phone for emergencies.

11b. Call 911*

I accept

11c. Got to the emergency room at Parkland Hospital or the closest to you*

I understand.

I voluntarily agree to receive online therapy services for an assessment, continued care, treatment, or other services and authorize Aurolina Valdés to provide such care, treatment or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment or services and that I may withdraw consent for such care, treatment or services at any time. By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.*

Clear

Date

Informed Consent for Tele-Mental Health Services