I am choosing to receive therapy services with a therapist from Positive Changes Counseling Center via the internet. By choosing this option, I understand that:

1. Teletherapy is the use of interactive audio, video or other telecommunications or electronic media that allows face-to-face communication between a therapist and client.

2. Teletherapy does not provide emergency services. If I am experiencing an emergency situation, I can call 911 or proceed to the nearest hospital emergency room for help. 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) or the Suicide Hotline 1-800-SUICIDE for free 24-hour hotline support.

3. I am responsible for providing the necessary computer, telecommunications equipment and internet access for my teletherapy session. I will make arrangements to secure a location with privacy that is free from distractions, intrusions or interruptions during my teletherapy session.

4. Any internet-based communication is not 100% guaranteed to be secure/confidential. The therapist has made every reasonable effort to implement technical security measures that reduce risks of a confidentiality breach. I understand the risk and I agree that Positive Changes Counseling Center and my therapist should not be held responsible if any outside party gains access to our therapy session.

5. The teletherapy session occurs in the state of Maryland and is governed by the laws of Maryland.

6. I understand that technical problems may occur. If a call is disrupted, the therapist will call back unless technical difficulties persist. In such cases, the session can be rescheduled via email or phone.

7. Teletherapy is possible once a client is an established client with the therapist. Teletherapy is not meant to be a long-term option; face-to-face therapy has proven to be most effective as the therapeutic method. In the event teletherapy is not in my best interest, my therapist will explain that to me and suggest alternative options better suited to my needs.

8. My consent to teletherapy can be withdrawn by providing written notification to my therapist. My signature below indicates that I have read this consent form and agree to its terms.

9. Teletherapy may not be covered by my health insurance policy. I agree to pay the session rate if my insurance does not cover teletherapy services.