I understand and agree to receive tele-mental health services from my therapist at Mindful Counseling LLC, which means that my therapist and I will, through a live interactive video connection, meet for scheduled psychotherapy sessions under the conditions outlined in this document.
I understand the potential risks of tele-mental health, which may include the following: 1) the video connection may not work, or it may stop working during a session; 2) the video or audio transmission may not be clear; or 3) my therapist may deem that tele-mental health services are not an appropriate method for me. I understand that it is my therapist’s discretion on what topics will be covered in my tele-health sessions.
I understand that my therapist uses HIPAA-compliant technology to transmit and receive video and audio. I understand that medical records of the telehealth sessions will be kept by Mindful Counseling LLC the same way in-person session medical records are kept; no copies of the video sessions themselves are kept in any form.
I understand that it is my responsibility to ensure that my physical location during videoconferencing is free of other people to ensure my confidentiality. Furthermore, I understand that recording my sessions is prohibited.
I understand that I have the option to request in-person treatment at any time, and my therapist will assist in scheduling this or make a referral if therapy at my therapist’s office is not feasible. I understand that I can withdraw my permission to participate in tele-mental health at any time, and that if I do not choose to participate in a tele-health session, no action will be taken against me that will cause a delay in my care and that I may still pursue in-person consultation.
I understand that there are limitations to confidentiality, and if my therapist reasonably believes that I plan to harm myself or someone else, my therapist will contact local emergency services to come to my location and ensure my safety. I agree to supply my therapist with my location for each session.
I represent that I am using my own equipment to communicate and not equipment owned by another, and not using my employer’s computer or network. I am aware that any information I enter into an employer’s computer can be considered by the courts to belong to my employer and my privacy may thus be compromised.
I agree that if my therapist has indicated I need to contact my insurance company to verify that my benefits include tele-mental health, I will do so, and that I will provide my therapist with the information I obtained and a call reference number. I agree that if I do not call my insurance company to verify benefits prior to utilizing tele-mental health, I will pay the private pay fee of $85/session if my insurance does not cover this therapy.
I have been given information about the benefits and limitations of telehealth sessions, including in cases of urgent and emergency behavioral health needs. I give my consent to engage in psychotherapy via videoconferencing and my signature below indicates that I agree to participate in tele-mental health under the conditions described in this document.