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Telemental Health Informed Consent

Telemental health informed consent 

By clicking the Read and Agree box below I certify that I have reviewed the below information regarding telemental health services, and agree to participate as part of my psychotherapy. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a client and practicioner who are located in two different locations. 

I understand the following with respect to telemental health:

1)                 I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

2)                 I understand that there are risks, benefits, and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

3)                 I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

 4)                 I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).

5)                 I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.

6) I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, we will end and attempt to restart the session.

7) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

8) I agree to inform my therapist of the address where I am at the beginning of each session in case of a life-threatening emergency. 

In case of emergency, my location is:
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