TELETHERAPY INFORMED CONSENT

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:

1. 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 .
2. I understand that I have the right to withdraw consent at any time without affecting my right to available future care .
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. I understand that my therapist may need to contact my em ergency contact and/or appropriate authorities i n the case of an emergency .

I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.