Consent to Videoconferencing and Teletherapy
Telehealth means the use of real-time interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services by a healthcare provider to deliver healthcare services to a patient within the scope of practice of the healthcare services provider when such provider is at a qualified site other than the site where the patient is located.
The use of videoconferencing and telephone services for therapy has been shown to be effective but also involves special considerations.
I understand that I have the following rights with respect to teletherapy:
The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including child, elder, and dependent adult abuse; threats of harm to self or others, or if court ordered.
I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of the therapist, that the transmission of my information could be disrupted or distorted by technical failures and the transmission of my information could be interrupted by unauthorized persons.
I understand that teletherapy based services and care may not be as effective as face- to-face services. I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may not improve, and in some cases may even get worse
I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.
I accept that teletherapy does not provide emergency services. If I am experiencing an emergency situation, I understand that 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) for free 24 hour hotline support, the TN Statewide Crisis line at 855-274-7471, or the local Mobile Crisis at 615-726-0125.
I understand that all payments will be processed through Square. I understand payment of fees is expected at the time of service. I will notify my therapist at least 48 hours in advance if I am unable to keep my appointment. Appointments not canceled 48 hours prior to the session will be charged.