“Telehealth” (also known as “Video Therapy” and “Telephone Counseling”) involves the delivery of psychotherapy counseling services using electronic communications, information technology or other means between a mental health clinician employed by or otherwise contracted with TMG (“Provider”) and a client who are not in the same physical location.
Telehealth may be used for diagnosis, treatment, follow-up and/or education, and may include, but is not limited to:
The vendor of the electronic systems used in the provision of Video Therapy Services (Zoom and/or other HIPAA compliant platform) has represented that it incorporates industry standard network and software security protocols to protect the privacy and security of health information.
Potential Benefits of Telehealth Services
Potential Risks of Telehealth Services
By accepting this Consent to Telehealth Services, you acknowledge your understanding and agreement to the following:
By signing below, I indicate agreement to the following:
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.