Telehealth Informed Consent - Central Behavioral Healthcare

Telehealth Consent

As a client receiving mental health services through telehealth methods, I understand:

1. This service is provided by technology (including but not limited to video, phone, text, and email) and may not involve direct, face to face, communication. There are benefits and limitations to this service. I will need access to, and familiarity with, the appropriate technology to participate in the service provided. Exchange of information will not be direct and any paperwork exchanged will likely be exchanged through electronic means or through postal delivery.

2. If a need for direct, face to face services arises, it is my responsibility to contact this office for a face to face appointment. I understand that an opening may not be immediately available.

3. I may decline any telehealth services at any time without jeopardizing my access to future care, services, and benefits.

4. These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over the internet that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. My provider and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of technology.

5. Important considerations for these services include: a. Only some methods and platforms are appropriate for delivery of these services. b. I need to use a webcam or smart phone during video sessions. c. It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. d. It is important to use a secure internet connection rather than public/free Wi-Fi. e. It is important to be on time. If I need to cancel or change my tele-appointment, I must notify the provider in advance by phone or email. f. We need a back-up plan (e.g., phone number where I can be reached) to restart the session or to reschedule it, in the event of technical problems. g. We need a safety plan that includes at least one emergency contact and the closest ER to my location, in the event of a crisis situation. h. I should confirm with my insurance company that the teletherapy sessions will be reimbursed; if they are not reimbursed, I am responsible for full payment.

6. In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means:

a. In emergency situations

b. Should service be disrupted

c. For other communication

7. My provider may utilize alternative means of communication in the following circumstances:

8. My provider will respond to communications and routine messages within a certain amount of time:

9. It is my responsibility to maintain privacy on the client end of communication. Insurance companies, those authorized by the client, and those permitted by law may also have access to records or communications.

10. I will take the following precautions to ensure that my communications are directed only to my provider or other individuals:

11. My communications exchanged with my provider will be stored in the following manner:

12. The laws and professional standards that apply to in-person mental health services also apply to Telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.

Client Name

Signature

Current Date

Name of Provider(Required)