Telemental Health
Telemental Health, also known as telehealth, refers to providing counseling services remotely through the use of interactive audio and video communication. The telehealth systems used will incorporate network and software security protocols to protect client confidentiality.
Consent to Telemental Health Services
I consent to telemental health services provided by Wellness Grove. I understand that these services include assessment, diagnosis, and/or treatment, that is deemed necessary by my clinician’s professional judgment.
I understand that:
- I must provide verification of my identity to my clinician.
- Due to certain limitations of telemental health, my clinician will determine whether or not my presenting issue is appropriate for a telehealth encounter.
- Should my clinician determine that a telehealth encounter is not appropriate for my presenting issue, I will be provided appropriate alternatives for my care.
- I am required to have technical competence on my part to participate in telemental health services to include, but not limited to, being able to use equipment (such as a laptop, PC, or phone) and connect to the internet.
- All confidentiality protections required by law or regulation will apply to my care.
- I will have access to all medical information resulting from the telemental health services as provided by law, and that my express permission is required before my medical information may be shared with a third-party, unless otherwise allowed by law.
- I have the right to refuse, or discontinue, mental health services via telemental health at any time without affecting my right to future care or treatment, and without risking any service benefits to which I would otherwise be entitled.
- If an emergency occurs during a telemental health encounter, I should call 911 and stay on the video or phone connection (if applicable) until help arrives.
Benefits of Telemental Health
I understand that telemental health has numerous benefits to include:
- Expanding access to clients who may not otherwise be able to participate in in-person counseling sessions
- Eliminating the need for transportation and travel-related costs
- Convenience in scheduling appointments
- Being an effective alternative to in-person counseling sessions as demonstrated by research
Risks of Telemental Health
I understand that there are potential risks with any form of counseling, including telemental health. I understand that potential risks associated with the use of telehealth systems include, but are not limited to:
- Despite personal and clinician efforts, the presenting issue may not improve, and in some instances may get worse
- Interruption of the audio/visual link
- Disconnection of the audio/visual link
- Distorted or blurred video
- Electronic tampering
- In extremely rare instances, a breach of privacy of private medical information due to failed security protocols
I understand that should any of these risks occur, the telemental health session may need to be stopped.
Telemental Health Session Protection
I understand that Wellness Grove has taken the appropriate security measures to ensure that each telemental health session is secure by providing the telehealth sessions through a HIPPA compliant platform, encrypting my healthcare data, and placing safeguards on the systems used to access my data.
Confidentiality and Records
I acknowledge and understand that my clinician has certain duties and obligations that may require the disclosure of my confidential information under certain situations, including, but not limited to: harm to self or others, child abuse, or elder abuse.
I also understand that my clinician may disclose my confidential information to any other person or entity of my choice upon receipt of a valid and executed release of information from me.
I understand that the telemental health sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I understand that my clinician will maintain a record of the sessions in the same ethical manner for in-person sessions.
Location for Telemental Health Sessions
I understand that different states have different regulations for the use of telehealth. I understand that in order for my clinician to participate in a telemental health session with me, I must be physically present within the state of Ohio. I understand that in order to ensure the confidentiality of my telemental health, I agree to participate in the session from a safe, private, and quiet environment and not record the session. If I am unable to meet this requirement, I understand that it is responsibility to discuss these issues with my clinician.
I understand that depending on my insurance plan, my insurance company may require a designated location that I must remain during the session for telemental health. I acknowledge and understand that I am responsible for understanding my coverage and requirements. I acknowledge and understand that it is my obligation to notify my clinician of my location at the beginning of each telemental health session. If for some reason I change locations during the session, I understand that it is my obligation to notify my clinician of the change in location.
Billing & Fees
I understand that the same fee rates and policies (including no-show and late cancellation) will apply for telemental health as they do for in-person therapy. I acknowledge and understand that while most insurance companies offer telemental health coverage, some do not. I understand that it is my obligation to understand my insurance policy before engaging in telemental health services to determine if there are applicable co-pays or fees which I am responsible for. I understand that if my insurance, HMO, third-party payor, or other managed care provider does not cover the telemental health sessions, I will be solely responsible for the entire fee of the session.
Crisis and Emergency Situations
I understand that certain situations including crises and emergency are not appropriate for telemental health services. I acknowledge and understand that if I am in a crisis or emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area. I understand that emergency situations include having thoughts of killing or harming myself or another person, hallucinating, experiencing a life-threatening or emergency situation of any kind, having emotional reactions that are uncontrollable, or experiencing dysfunction due to abuse of alcohol or other drugs.
I acknowledge I have been told that if I feel suicidal, I am to contact one of the following resources:
- Emergency Services (911)
- National Suicide Prevention Lifeline (1-800-273-8255)
- Crisis Text line (Text: HOME to 741741)
Emergency Contact
I understand that assessing and evaluating threats and other emergencies can be more difficult when conducting telemental health sessions than traditional in-person treatment. I understand that my clinician may need to call my emergency contact in the event of a crisis or emergency in order to promote my safety.