Liberated Counseling, LLC

• This form will go over a little bit about telehealth, how to electronically complete intake and other paperwork, and will help you set up the tools for our video telehealth sessions.
• We will use secure, encrypted technologies that are free to you for video sessions.
• Telehealth has both benefits and risks, which we will be monitoring as you proceed with your work.
• You can stop work by telehealth at any time without prejudice.
• You will need to participate in creating an appropriate space for your telehealth sessions.
• You will need to participate planning for technology failures, mental health crises, and medical emergencies.
• I follow security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy.

Telehealth means the providing of mental health counseling through secure video software. Services delivered via telehealth rely on a number of electronic, Internet-based, programs. I provide telehealth via a secure application called vsee messenger or a secure website called doxy:

• Vsee messenger can be downloaded for free here: https://my.vsee.com/download
• If you prefer, we can also meet through the secure doxy website. My doxy’s website is https://doxy.mee/sratcliff
• You will need access to high speed Internet service for your telehealth session.
• If you have any questions or concerns about the above tools, please let me know.

• Receive services when you are unable to travel to the service provider’s office.
• Receive services at times or in places where the service may not otherwise be available.
• Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings.
• Receive services without potential risks of transmission of COVID 19 or other transmittable viruses.
• The unique characteristics of telehealth media may also help some people make improved progress on health goals that may not have been otherwise achievable without telehealth.

Telehealth services can be impacted by technical failures, may introduce risks to your privacy, and may reduce my ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples:

• Internet connections and cloud services could cease working or become too unstable to use.
• Computer or smartphone hardware can have sudden failures or run out of power, or local power services can fail.
• Interruptions may disrupt services at important moments, and I may be unable to reach you quickly.

• Although it is well validated by research, service delivery via telehealth is not a good fit for every person. I will continuously assess if working via telehealth is appropriate for your case. If it is not appropriate, I will help you find in-person providers or shift to in-person sessions.
• Please talk to me if you find the telehealth media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the telehealth medium seems to be causing problems in receiving services.
• Bringing your concerns to me is often a part of the process. You also have a right to stop receiving services by telehealth at any time without prejudice.

You will be responsible for creating a safe and confidential space during sessions. Please consider:

• Dress as you would if we were meeting in an office appointment.
• If you have a headset with a microphone, please use it as this helps produce better audio and privacy.
• Please be in an environment where you are alone and have good access to high speed internet.
• Please limit distractions such as multi-tasking. Please turn on do not disturb if you are meeting on your cell phone.
• Have your computer or tablet on a firm surface if possible.
• Please avoid walking around with your device, as this can make me dizzy.

If you need to get ahold of me in between sessions, here are some contact methods and considerations:

• The best way to contact me between sessions is by email steve@liberatedcounseling.com or telephone 505-504-5449. Please note that neither email nor my telephone number are to be used during a crisis.
• I will respond to your messages as soon as I can. Please note that I may not respond at all on weekends or holidays.
• Our work is done primarily during our appointed sessions, which will generally occur during my business hours Monday thru Thursday from 10am to 7pm.
• Contact between sessions should be limited to confirming or changing appointment times.

As a recipient of telehealth services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with me.

• I will require you to designate an emergency contact at the intake appointment. You will need to provide permission for me to communicate with this person about your care during emergencies.
• Crisis services include Telephone crisis lines (800-273-8255 or 505-277-3013), calling 911, or go immediately to the nearest Emergency Room.
• Except where otherwise noted, I employ software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged.
• As with all things in telehealth, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with me, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that I have supplied for communications (e.g. Vsee). For more information please see my specific recommendations for electronic security and safety here: http://steveratcliff.com/techrec.pdf

 

Vsee messenger can be downloaded for free here: https://my.vsee.com/download

• After you download and install vsee messenger onto a tablet, computer, or smart phone, you will need to set up an account. This process if free but will include using an email address for that account.
• If you have problems downloading vsee messenger, let me know and I can email you a download invite
• After you have set up the application and account, let me know what email address you used, and I will reach out to you through the application to connect us.
• After we are connected, we can send messages, do video sessions, and exchange files securely through the end-to-end encryption that vsee messenger uses.
• A video showing some of the basic functions of the vsee messenger application is here: https://youtu.be/XZlCfj07MUQ 

If you prefer, we can also meet through the secure doxy website, which is https://doxy.me/sratcliff

• Click on the link and check in a few minutes prior to our appointment time using whatever name you’d like.
• It will ask you to enable access to your microphone and camera. Click yes.
• I will start the appointment at our appointment time.
• This webpage is a tutorial for doxy https://help.doxy.me/en/articles/3751218-how-to-check-in-as-a-patient

Call me at 505-504-5449 if there are technical difficulties.

Please do not record video or audio sessions without my consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. I will not record video or audio from our sessions.

• Currently, telehealth services are only permitted to residences of New Mexico, Oregon, and Florida due to licensure law restrictions. Many insurance companies cover some or all of the cost of services delivered by telehealth. Currently, many New Mexico insurance plans including New Mexico Medicaid cover telehealth services. If you have questions about coverage of telehealth, please contact your insurance company.
• Copays and deductibles will be due at the time of service during a telehealth session similar to an in-office session. These fees will be collected by cash, check, credit card, HSA, or FSA means.
• Any credit card, debit card, HAS, or FSA payments will be collected using a secure service called Ivy, which keeps your card on file. I will never charge your card without your permission. Your signature at the bottom of this form indicates your consent to Ivy maintaining your chosen card on file. I can delete your card information upon request.

Prior to our first appointment and periodically throughout therapy, we will need to complete paperwork. I have made my forms fillable online for your convenience. Here are some tips to help you fill out these forms:

• You may fill out forms securely through the links on my website: www.steveratcliff.com

OR

• You can fill out forms securely through a website called jotform. If you would like the link to fill out documents electronically, please check on my website www.liberatedcounseling.com or ask me!
  
  

Our signatures below attests to the fact that:

• WE have residency in either the state of New Mexico, Oregon, or Florida.
• WE agree to participate in telehealth-based psychotherapy.
• WE have read, understood, and agree to follow the above policies.
• WE consent to having our electronic payment information stored on Ivy.