Telehealth Consent
I hereby consent to engage in telehealth as a part of my counseling treatment plan. I understand that “telehealth” includes the practice of mental health care delivery, diagnosis, consultation, treatment, and transfer of medical data using interactive audio, video, or data communications. I understand I have the following rights and responsibilities concerning telehealth.

1. I have the right to withhold or withdraw consent at any time without affecting my right to future care.

2. The laws that protect the confidentiality of my medical/health information also apply to telehealth. As such, I understand that the information disclosed during my therapy is generally confidential. However, there are both mandatory and permissive expectations to confidentiality, including but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

3. I understand that there are risks and consequences from telehealth, including, but not limited to the possibility, despite reasonable efforts on the part of my therapist, that the transmissions of my medical/health information could be disrupted or distorted by technical failures. In addition, I understand that telehealth-based services and care may not be as complete as face-to-face service.

4. I understand that I am responsible for securing my own encrypted wi-fi/internet connection before the start of any telehealth session.

5. I understand I am responsible for securing a private location before the start of any telehealth session.

6. I accept responsibility to communicate my need to cancel or reschedule my telehealth session with SCA at least twenty-four hours before the appointment. I realize my failure to call and speak directly with administrative staff or to leave a voice message advising of my need to cancel & or reschedule will result in a missed appointment fee of up to $50.00 (fifty dollars).