I hereby consent to participate in telemental health with my therapist, Anne G. Walker LCSW, as part of my psychotherapy. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and client who are in two different locations at one time.
I understand the following with respect to telemental health:
1. I understand that there are risks and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
2. I understand there will be no recording of any of the online sessions by either party and that state law requires consent by both parties. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written consent, except where the disclosure is permitted by law. Unauthorized recording is prosecutable by law. I agree to make every effort to secure privacy in my location, including use of headphones as necessary. If discovered that an unauthorized recording has occured by a third party, I agree to notify my therpist immediately.
3. I understand the privacy laws that protect PHI also apply to telemental health, unless an exception to confidentiality applies, such in the case of mandated reporting of child, elder or vulnerable adult abuse; danger to self or others; or court mandated legal processes.
4. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely it may be determined that telemental health services are not appropriate and a higher level of care is required.
5. I understand that during a telemental health session we may encounter technical difficulties resulting in service interruption. If this occurs we will end and restart the session. If we are unable to reconnect within ten minutes please call (847) 754-3933 to discuss next steps.
6. I understand that my therapist my need to contact my emergency contact and/or appropriate authorities in case of an emergency.