Telehealth Visit Consent to Treat
I consent to telehealth with a provider at Clinic with a Heart. Telehealth is a broad term that refers to physical and mental health services and information provided electronically or with the use of technology.
I understand telehealth may include health education, diagnosis, consultation, treatment, and referrals to resources. Telehealth will occur primarily through telehealth services, telephone conversations, and may involve email exchanges.
I understand that I have the following rights and responsibilities with respect to telehealth:
- The right to withhold or withdraw consent at any time. If consent is withheld or withdrawn, your provider may need to refer you to another community mental or physical health provider.
- The use of telehealth is subject to the discretion of the provider, is temporary in nature, and based on the assessment of clinical needs. For new clients, telehealth will only occur after participating in a phone screening. After completion of the screening, the provider will inform
you if participating in telehealth is appropriate. Receiving telehealth may be contraindicated by:
** Recent suicide attempt(s), psychiatric hospitalization, or psychotic symptoms
** A clinical presentation with severe physical symptoms (e.g. severe eating disorder, severe depression) that requires medical attention
** Moderate to severe substance abuse or dependence symptoms
** Repeated “acute” crises (e.g., occurring once a month or more frequently)
For you to receive telehealth, per state law, you must be physically located in Nebraska. Your
provider will confirm your location at the beginning of each telehealth session.
** You are required to disclose to the provider your exact location at the time of each
5. Telehealth appointments occur at the times agreed upon between you and your provider. If you
are unable to make your appointment, please contact Clinic with a Heart as soon as possible. If
you miss your appointment without calling first, another appointment will not be rescheduled.
Clinic with a Heart at 402-421-2924.
6. The laws that protect the confidentiality of your personal information and clinical treatment
record also apply to telehealth. As such, the information disclosed during the course of
telehealth sessions is generally confidential. However, there are exceptions to confidentiality,
including, but not limited to:
You are in imminent danger of harm to self or others and it is necessary to ensure yours
and/or other’s safety
The provider has reason to suspect the presence of abuse or neglect of a child, an
elderly person, or dependent adult; and must make a mandatory report to Health and
Clinic with a Heart
1701 S. 17th Street, Ste 4G
Lincoln, NE 68502
7. I understand that the provider will not record my sessions via telehealth nor will I record any
8. I understand that there are risks and consequences from telehealth, including, but not limited
to, the possibility, despite reasonable efforts, that:
The transmission of my personal information could be disrupted or distorted by
The transmission of my personal information could be interrupted by unauthorized
Unauthorized persons could access the electronic storage of my personal information.
Another risk is that you may experience loss of confidentiality due to factors from the
surrounding environment in which you choose to participate in telehealth. You are
encouraged to ensure that no one else is in the room, not to participate in
conversations while on speakerphone, and not to participate in a public space.
In addition, telehealth may not be as complete as face-to-face services. You may benefit
from telehealth, but results cannot be guaranteed or assured.
9. Should there be technical problems with telehealth, the most reliable backup plan is contact by
phone. Make sure that Clinic with a Heart has a correct phone number at which you can be
reached, and have your phone with you at session times.
10. I understand that I have a right to access my personal information and copies of case records in
accordance with Federal and Nebraska law.
11. I have read and understand the information provided above. I understand that if I have any
questions I am free to discuss them with my provider.
12. By signing this document, I agree that certain situations including emergencies and crises are
inappropriate for telehealth services.
If I am in crisis or in an emergency I should immediately call 9-1-1, the National
Suicide Hotline at 1-800-273-8255, or seek help from a hospital or crisis-oriented
health care facility in my immediate area.
I understand that emergency situations include if I have thought about hurting or
killing either another person or myself, if I have hallucinations, if I am in a lifethreatening or emergency situation of any kind, having uncontrollable emotional
reactions, or if I am dysfunctional due to abusing alcohol or drugs.
I acknowledge I have been told that if I feel suicidal, I am to call 9-1-1 or other local
Your signature below indicates that you have read the information in this document
and agree to abide by its terms.