Teletherapy Informed Consent Form

By signing below, I consent to engaging in teletherapy with the therapists at Austin Women Counseling as part of my mental health treatment. Terms for distance therapy include "teletherapy" "telemedicine" and "electronic therapy" and will henceforth be referred to in this document as teletherapy. I understand that teletherapy includes the practice of mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications such as the telephone, cellular phones, the Internet, and various programs such as Google Meet, Doxy.me, and other relevant programs. I understand that I have the following rights with respect to tele-therapy:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my health information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting abuse or neglect of children, the elderly, dependent adults, and the incarcerated. Further limits include expressed threats of violence towards oneself or others; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the teletherapy interaction to other entities shall not occur without my written consent.

(3) I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my health information could be disrupted or distorted by technical failures; the transmission of my health information could be interrupted by unauthorized persons; and/or the electronic storage of my health information could be accessed by unauthorized persons. I also understand that the programs listed above have their own policies that might interfere with confidentiality and I am fully aware of the risks associated with working with these programs. In addition, I understand that tele-therapy and electronic therapy-based services and care may not be as complete as face-to-face services. I also understand that if my therapist believes I would be better served by another form of psychological services (e.g. face-to face services) I will be referred to a practitioner who can provide such services in my area, if available. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may not improve, and in some cases

(4) I understand that teletherapy is not the recommended modality of treatment for many clients including, but not limited to: clients who are actively suicidal or homicidal, clients with active substance abuse issues, clients with severe psychiatric conditions, clients in violent situations, etc. I understand that if I am identified as falling into the previous categories, or others, that I may be offered a referral to another therapist who utilizes a modality that will be better suited to my needs or need to transition to traditional in-person sessions, if medically able and appropriate. Additionally, I may be asked to consent to an additional "Safety Plan" in order to protect my safety given the nature of the risk I present with.

(5) I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured.

(6) I understand that I have a right to access my health information and copies of records in accordance

(7) I understand that there are many ways to communicate with my therapist but the most secure ways to communicate with her are through either a telephone call OR the secure email system.

While security is often a perception and nothing truly can be guaranteed due to the laws of our government, the secure messaging system and the therapist's email account have also had reasonable steps taken to make it HIPAA compliant and secure. Brianne has taken every measure in her power to ensure that your information and data is secure and by signing this form, you acknowledge that there is still a possibility that your information could be accessed.

By signing my name below I certify that I have read and consent to the above policy.