Tele-therapy Informed Consent

I _________________________ hereby consent to engage in tele-therapy with my therapist at as an alternative to meeting for face-to-face sessions. I understand that tele-therapy involves engaging in therapy sessions through the use of a HIPAA complaint platform (such as that will allow interactive audio and video communications.

I understand I have the following rights with respect to tele-therapy:

1)    I have the right to withhold or remove consent at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.

2)    The laws that protect the confidentiality of my personal information also apply to tele-therapy. As such, I understand that the information released by me during the course of my sessions is generally confidential. There are both mandatory and permissive exceptions to confidentiality including but not limited to reporting child and vulnerable adult abuse, expressed imminent harm to oneself or others, or as a part of legal proceedings where information is requested by a court of law. I also understand that the dissemination of any personally identifiable images or information from the tele-therapy interaction to other entities shall not occur without my written consent.

3)    I understand that there are risks and consequences from tele-therapy including but not limited to, the possibility, despite reasonable efforts on the part of my therapist that: the transmission of my personal information could be disrupted or distorted by technical failures and/or the transmission of my personal information could be interrupted by unauthorized persons.

4)    In addition, I understand that tele-therapy based services and care may not be as complete as in-person services. I understand that if my therapist believes I would be bettered served by other interventions I will be referred to a mental health profession who can provide those services in my area. I also understand that there are potential risks and benefits associated with any form of mental health treatment, and that despite my efforts and the efforts of my therapist, my condition may not improve, or may have the potential to get worse.

5)    I understand that I may benefit from tele-therapy services, but that results cannot be guaranteed or assured. I understand that my therapist will conduct tele-therapy using a HIPAA complaint platform and all attempts to keep information confidential while using these systems will be made, however a guarantee of 100% confidentiality cannot be made with inherent issues with these communication systems. Signing this form shows an awareness of these issues and a decision by this client to use these systems for tele-therapy services.

6)    By signing this document, I agree that certain situations including emergencies and crises may not be inappropriate for tele-therapy. If I am in crisis or in an emergency, I should immediately call 911 or go to the nearest hospital or crisis facility. I understand that emergency situations may include thoughts about hurting or harming myself or others, having uncontrolled psychotic symptoms, if I am in a life threatening or emergency situation, and/or if I am abusing drugs or alcohol and am not safe. By signing this document, I acknowledge I have been told that if I feel suicidal, I am to call 911, local county crisis agencies or the National Suicide Hotline at 1-800-784-2433.


Signature of client/parent/guardian                 Date

Printed name of client/parent/guardian

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