I authorize Dr. Glenda Martinez, licensed clinical psychologist by the state of Florida, to provide diagnostic testing and/or psychotherapeutic services as required. I understand that I may withdraw my consent, at any time to the extent permitted by law. I have the right to confidentiality under the same laws that protect the confidentiality of my medical information for in-person service. Any information disclosed by me during the course of my session is generally confidential.
POLICY ON CONFIDENTIALITY OF INFORMATION (LIVE AND TELEHEALTH)
Any communication between Dr. Glenda Martinez and her patients or clients shall be confidential and shall not be disclosed to anyone without expressed written permission or a court order. However, this privilege may be waived under the following conditions:
When there is clear and immediate probability of physical harm to the patient or the client, to other individuals or to society and Dr. Glenda Martinez communicates the information only to the potential victim, appropriate family member, law enforcement or other appropriate authorities.
Information disclosed regarding abuse of any protected group will be reported according to the guidelines specified by Florida Law.
If Dr. Glenda Martinez is a party defendant to civil criminal, or disciplinary action arising from a complaint filed by the patient, client or said representative, in which case the waiver of confidentiality shall be limited to that action.
When the patient or client agrees to the waiver, in writing, or when more than one person in a family is receiving therapy, when each family agrees to the waiver in writing.
When the patient or client is using national, state or private insurance, group insurance or any other type of third party payers to pay for services received from Dr. Glenda Martinez said organization requires information for the purposes of determining eligibility for payment. In such cases, care will be taken to protect the client or patient in providing only required information.
In the event that Dr. Glenda Martinez cannot continue practicing due to debilitating illness or death, they will establish an agreement with local mental health professional to ensure the continuity in confidentiality and security of the patient records and will thereby assign the privilege to said mental health professional.
I understand that while service have been found to be effective in treating a wide range of mental disorders and personal and relational issues, there is no guarantee that all treatment of all clients will be effective. Thus, I understand that while I may benefit from telehealth, results cannot be guaranteed or assured.
I understand that telehealth treatment is different from in-person therapy/consultation and that if my provider believes I would be better served by another form of service, such as in-person treatment, I will be referred to a provider in my geographic area for such service.
I accept that telehealth does not provide emergency services. During our first Telehealth session, my provider will discuss an emergency response plan, which will include contacting the listed emergency contact and/or 911 for the address listed. If I am experiencing an emergency situation, I understand I can call 911 or proceed to the nearest hospital emergency room. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273 TALK (8255) for free 24-hour hotline support.
I understand I am responsible for 1) providing the necessary computer, telecommunications equipment, and internet access for my telehealth sessions; 2) maintaining the information security on my computer; and 3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my telehealth session.
I understand that I cannot be driving at the time of my session. If I am to take my telehealth session within my vehicle, I must be parked.
I understand that it is my responsibility as the client to call my insurance company and ask if the benefits under my plan cover telehealth and telemedicine sessions.