Information and Informed Consent for All Past and Future Telehealth Treatments

Telehealth is live two - way audio and video electronic communications that allows therapists and clients to meet outside of a physical office setting. 

Client Understanding

I understand that telehealth services are completely voluntary and that I can withdraw this consent at any time.

I understand that none of the telehealth sessions will be recorded or photographed without my consent.

I agree not to make or allow audio or video recordings of any portion of the sessions.

I understand that the laws that protect privacy and the confidentiality of client information also apply to telehealth, and that no information obtained in the use of telehealth that identifies me or my child will be disclosed to other entities without my consent.

I understand that OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency, including but not limited to Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, and Skype.

I understand there are potential risks to using this technology, including interruptions, unauthorized access, and technical difficulties.

I understand that I or my therapist may discontinue the telehealth sessions at any time if it is felt that the video technology is not adequate for the situation.

I understand that if there is an emergency during a telehealth session, then my therapist may call emergency services and/or my emergency contact.

I understand that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment, and that all office policies and procedures apply to telehealth services. I understand that if the video conferencing connection drops while I am in a session, I will have an additional phone line available to contact my therapist, or I will make additional plans with my therapist ahead of time for re-contact.

I understand my therapist will advise me about what telehealth platform to use and she will establish a video conference session.

Please click the button above to digitally sign the Telehealth Consent Form. You will be asked to input your name and email address before accessing the form. You will have the option to download the signed form once you have submitted it.