The Team

TELEHEALTH AGREEMENT AND INFORMED CONSENT 

1. CONSENT FOR TELEHEALTH SERVICES 

I request, consent, and authorize my therapist to provide mental health services using telehealth through the DoxyMe platform or via telephone sessions as an alternative. I understand that teletherapy includes consultation, treatment, transfer of medical data, emails, telephone conversations, text messages, and education using interactive audio, video, or data communications. I also understand that teletherapy also involves the communication of my mental health/medical information, both orally and visually. I have the right to withdraw or withhold consent from teletherapy services at any time. I also have the right to terminate treatment at any time.  

2. CONFIDENTIALITY 

I understand that unless explicitly agreed otherwise, teletherapy exchange is strictly confidential. Any information I choose to share with my therapist will be held in the strictest confidence. Just like in face-to-face sessions, my therapist will not release my information to anyone without my prior approval unless required to do so by law. 

Exceptions to confidentiality are: 

· Medical emergency 

· Threats of suicide/bodily harm to self or others 

· Suspected child abuse or neglect 

· Suspected elder abuse or neglect 

· In some situations, a judge can force surrender of medical records. 

· I understand that state law is not specific regarding situations when therapist/client privilege does not apply in the normal course of doing business/to receive payment. 

· Staffing with other professionals to provide the best care possible to me.

3. RISKS AND CONSEQUENCES  

I understand that there are risks and possible consequences with teletherapy services including, but not limited to, the possibility, despite reasonable efforts on my part, that:  

· The transmission of my medical information could be disrupted or distorted by technical failures. I understand that if tech failures occur, my therapist will work to restore connection. 

· The transmission of my information could be intercepted by unauthorized persons. 

· The electronic storage of my medical information could be accessed by unauthorized persons. due to complexities and abnormalities involved with the Internet and cell phones. This includes but not limited to, viruses, Trojans, worms, and other involuntary intrusions that have the ability to obtain and disseminate information I wish to keep private. If I have smart home devices, recording devices, etc., in the location where I will be attending teletherapy sessions, I am advised to turn them off for the duration of the sessions to protect my privacy. 

4. LIMITATIONS OF TELEHEALTH 

I understand that teletherapy based services and care may not be as complete as traditional face-to-face services. While teletherapy is a great way to get help with many of life’s problems, potentially dangerous challenges are best met with face-to-face professional support. I understand that teletherapy is neither a universal substitute, nor the same as face-to-face psychotherapy. I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured.

5. MENTAL HEALTH CRISIS PLAN 

I understand and accept that teletherapy does not guarantee/provide emergency services. If I am experiencing a mental health emergency and cannot contact my therapist, I understand that the protocol is to 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 may also call the National Suicide Prevention Lifeline at 1- 800-273-TALK (8255) for free 24-hour hotline support or text CONNECT to 741741 for support. 

6. MY RESPONSIBILITIES 

I will be responsible for the following: 

· Providing the computer and/or necessary telecommunications equipment and Internet access for your teletherapy sessions; 

· Securing or encrypting protected health information (PHI) transmitted to or stored on my computer/ telecommunications device; and 

· Arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy sessions. 

7. MY RIGHTS

I have the right to access my medical information and copies of my medical records in accordance with HIPAA privacy rules and applicable state law. I understand that my records are kept in an electronic health record system designed for this purpose with encryption and protections in place. 

8. ACKNOWLEDGMENT 

By my signature I acknowledge that I have read and understand the information provided above. I have discussed this informed consent with my psychotherapist, and all of my questions have been answered to my satisfaction. That while email, text messages, and/or telephone calls may be used as a form of communication with my therapist, that confidentiality of these types of communication cannot be guaranteed.

Client( s) Signature  Date 

Client (s) Printed Name 

Parent/Guardian Signature  Date 

Parent/Guardian Printed Name