I understand and agree to receive telemental health services from my therapist, Tonya Rowe. This means that my therapist and I will, through a live interactive video connection, meet for scheduled psychotherapy sessions under the conditions outlined in this document and the Hope Restored Services consent to services form.
I understand the potential risks of telemental health, which may include the following: 1) the video connection may not work, or it may stop working during a session; 2) the video or audio transmission may not be clear; 3) I may be asked to go to my therapist’s office in person if it is determined that telemental health is not an appropriate method of treatment for me.
I recognize the benefits of telemental health, which may include the following: 1) reduced cost and time commitment for treatment due to the elimination of travel; 2) ability to receive services near my home or from my home; and 3) access to services that are not available in my geographic area.
I give my consent to engage in psychotherapy via videoconferencing. I understand that my therapist uses HIPAA compliant technology to transmit and receive video and audio and stores all notes and information related to my treatment in a manner that is compliant with state and federal laws. It is my responsibility to ensure that my physical location during videoconferencing is free of other people to ensure my confidentiality. Furthermore, I understand that recording my sessions is prohibited. I give my consent to engage in psychotherapy via telephone as a last resort in the event video technology is not available.
I understand that I have the option to refuse teletherapy treatment at any time. I understand that I have the option to request in-person treatment at any time, and my therapist will assist in scheduling this or make a referral if travel to the office is not feasible. I understand that emergencies must be referred to 911 or my local Crisis Unit. The limitations to confidentiality with my therapist include reasonable belief that I am a danger to myself or others. If my therapist reasonably believes that I plan to harm myself or someone else, local emergency services will be contacted to come to my location to ensure my safety.
My signature indicates that I agree to participate in telemental health under the conditions described above.