I understand that teletherapy is the practice of delivering clinical mental health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.
I understand the following with respect to teletherapy:
-
I understand that teletherapy service
s are available on
l
y to tho
se
clients
who are resident
s
of
Illinois
, as t
herapists are only
permitted to provide
clinical
services to those living in the state
where
th
e thera
pist is
l
icense
d
.
-
I understand that I have the right to withdraw consent at any time without affecting my right to
available
future care
.
-
I understand that there are risks, benefits, and consequences associated with
teletherapy
,
including but not limited to,
disruption of transmission by technology failures
an
d/or limited ability to respond to emergencies.
-
I understand that there will be no recording of any of the online sessions by either party. I
nformation disclosed within
sessions and written records pertaining to those sessions are
confidential and m
ay not be disclosed to anyone without
written authorization, except where the
disclosure is permitted and/or required by law.
-
I understand that the privacy laws that protect the confidentiality of my protected health information
(PHI)
in
traditional
psychotherapy
also apply to
teletherapy
servi
ces.
-
I understand that if I am ha
ving suicidal or homicidal thoughts, actively experiencing psychotic
symptoms or experiencing a
mental health crisis that cannot be resolved remotely, it may be
determined that
teletherapy
services are not appropriate
and a higher level of care is re
quired.
-
I understand that during a
teletherapy
session, we could encounter technical difficulties
resulting in service interruptions. If
this occurs,
we will
end and restart the session. If we are unable
to
reconnect within ten min
utes,
we will
communicate
about rescheduling
the session.
-
I
understand that
PeoplePsych
need
s
to know
my
location
and I
agree to inform
my
therapist
of the address
where
I
am
at the beginning of each session.
-
I
understand that my therapist may need to contact my em
ergency contact and/or
appropriate authorities
i
n the case of an
emergency
.