Therapy via Telehealth
Telehealth allows clinicians and specialists the ability to provide a diagnosis, consultation and treatment for mental health needs using videoconference technology via telephone or computer. The purpose of the Telehealth Consent Form is to gain permission from clients to participate in telehealth therapy services.
Recordings of any kind will not be conducted during online sessions, neither by the client nor by the clinician without prior consent obtained from both parties. Medical and personal information of clients are protected by state and governmental laws, the same as they are for in-office appointments. It is the client's obligation to notify the clinician of their location at the beginning of each treatment session. If for some reason, you change locations during the session, it is your obligation to notify your clinician of the change in location. It is the client's obligation to notify the clinician of any other persons in the location, either on or off-camera and who can hear or see the session. The client will be responsible to ensure privacy at their location. The client will notify the clinician at the outset of each session of any confidentiality concerns and will be aware that confidential information may be discussed at the session. The client and clinician will also take steps to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, will be disabled or will not be in the location where information can be heard.
Risks & Benefits
Telehealth therapy aims to provide a complete treatment to clients in lieu of in-office sessions and may provide benefits including but not limited to easier access to care. It is considered and supported by research that online counseling is an effective therapeutic modality in treating a wide array of disorders, personal issues, and problems. However, it may not be beneficial for some and there is no guarantee that therapy will be effective for all clients.
Use of Technology
Clients and clinicians understand there are potential risks to using telehealth technology, including but not limited to, interruptions, unauthorized access, and technical difficulties. Some of these technological challenges include issues with software, hardware, and internet connection which may result in an interruption. Neither party will be held responsible for any technological problems of which they have no control over, nor guarantee that technology will be available or work as expected. The clinician and client will agree beforehand what steps to take should the technology fail. Both the client and clinician understand that they are responsible for information security on any device utilized, including but not limited to, computer, tablet, or phone, and in their own location. It is understood that the clinician or the client (or, if applicable, a guardian or conservator), can discontinue the telehealth consult/visit if it is determined by either the client or the clinician that the videoconferencing connections or protections are not adequate for the situation.
Payment & Cancellations
Clients agree that they are responsible for paying any additional cost or payment that their insurance providers do not cover. Cancellations must be made no later than 24 hours prior to the time of the designated session. Failure to do so will result in a $50 late cancellation fee that the client will be responsible to pay, while missing the session altogether will result in a $100 no show fee. Insurance cannot be billed for the cost of a late canceled or missed session.
Clients can withdraw and withhold this consent at any time, and can end the treatment any time they would like to. Any action of clients will not affect the future treatment of or accessibility to therapy services.
By signing this document, I acknowledge:
1. The telehealth platform is NOT an emergency service. In the event of an emergency, I will use a phone to call 9-1-1 and/or other appropriate emergency contact.
2. I recognize my clinician may need to notify emergency personnel in the event he/she feels there is a safety concern, including but not limited to, a risk to self/others or my clinician is concerned that immediate medical attention is needed.
3. Though my clinician and I may be in virtual contact through telehealth services, neither the telehealth platform nor my clinician provides any medical, emergency, or urgent healthcare services. I understand should medical services be required, I will contact my physician. If emergency services are needed, I understand I should call 9-1-1 or a local mobile crisis unit.
4. The telehealth platform itself facilitates videoconferencing and this technology platform is not, itself, a source of healthcare, medical advice, or care.
5. I understand that the same fee rates apply for telehealth as apply for in-person treatment. Some insurers are waiving co-pays during this time. It is my obligation to contact my insurer before engaging in telehealth to determine if there are applicable co-pays or fees which I am responsible for. Insurance or other managed care providers may not cover telehealth sessions. I understand that if my insurance, HMO, third-party payor, or other managed care provider do not cover the telehealth sessions, I will be solely responsible for the entire fee of the session.
6. To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.
7. I understand that either I or my clinician can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me. I understand there may be no other treatment alternative available.
I have read and understood the information provided above regarding telehealth, and I hereby give informed consent to the use of telehealth.