Teletherapy Consent Form

  • Definition of Services

    I, hereby consent to engage in teletherapy. Tele- therapy is a mental health service provided via internet technology, using interactive audio and video communications. I also understand that teletherapy involves the communication of my medical/mental health information, orally and/or visually.

    Teletherapy has the same purpose or intention as psychotherapy conducted in person. However, due to the nature of the technology used, I understand that teletherapy may be experienced somewhat differently than face-to-face treatment sessions.

    I understand that I have the following rights with respect to teletherapy:

    Client’s Rights, Risks, and Responsibilities

    1. I need to make sure that while engaged in teletherapy I am located in a jurisdiction where my practitioner is licensed.
    2. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
    3. 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, which are described in the general Informed Consent Form.
    4. I understand that there are risks and consequences of participating in teletherapy, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my therapist, that:
      • the transmission of my information could be disrupted or distorted by technical failures;
      • the transmission of my information could be interrupted by unauthorized persons;
      • the electronic storage of my medical information could be accessed by unauthorized persons.
    5. I accept that my practitioner’s capacity to respond to emergencies during teletherapy is limited. If I am experiencing an emergency situation, I understand that I should ccall 911 or proceed to the nearest hospital emergency room for help.
    6. In many cases, teletherapy is reimbursed by insurance at the same rate as person-to-person psychotherapy. However, I understand that policies may differ, and that I should check with my insurance carrier for the precise reimbursement rates.
    7. I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in teletherapy. I am responsible for
      • providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions
      • arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.
      It is the responsibility of the therapist to do the same on their end.
    8. I understand that dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.

    I have read, understand and agree to the information provided above regarding telehealth.

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  • This field is for validation purposes and should be left unchanged.

Updated: 7/10/2020

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