Technology Consent to Treatment

This form is designed to allow you to give informed consent for the use of video technology for online therapy. Read it thoroughly for understanding and ensure all of your questions are answered before signing to give consent.

Please correct the errors described below.

This is to be used as an addendum to the Consent to Treatment document that is required of all clients prior to starting therapy services.

Online Therapy / Telehealth / Teletherapy

Online therapy or teletherapy is defined as the use of technology to have a therapy session. The provider uses [INSERT TELETHERAPY PLATFORM], a HIPAA-compliant platform that uses video and audio technology through a webcam on your device and the provider's device to connect you securely.

The benefits of teletherapy include the convenience of location, time, wait times, and accessibility which allows for better continuity of care. In addition, teletherapy allows for greater accessibility to services for clients with limited mobility or with lack of transportation. Teletherapy can also allow for couples or families to meet when in different locations.

With all technology, there are also some limitations. Technology may occasionally fail before or during your session. The problems may be related to internet connectivity, difficulties with hardware, software, equipment, and/or services supplied by a 3rd party. Any problems with internet availability or connectivity are outside of the control of the provider and the provider makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video, the provider will either use the in-session video chat to troubleshoot or will call you to complete the session. Please list the number to call you in case this occurs (preferably your cell phone number) here:

If you are in an immediate crisis or a potentially life-threatening situation, get immediate emergency assistance by calling 911.

Communication via Email and Text (SMS)

The provider uses an encrypted, HIPAA compliant email platform called Hushmail to perform email communications with clients. The provider's email address is [INSERT EMAIL ADDRESS] and all email communications should be sent to/from this email address.

The provider cannot guarantee, but will always use reasonable means to maintain the security and confidentiality of email, phone, voicemail, and text information sent and received. The provider is not liable for improper disclosure of confidential information that is not caused by the provider’s intentional misconduct.

The provider will return emails/text messages as soon as possible, but cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time.

Email and texting is not appropriate for urgent or emergency situations. If you experience a mental health emergency, please go to your nearest emergency room and/or call 911.

I agree to take full responsibility for the security of any communications or treatment on my own computer and in my own physical location. I understand I am solely responsible for maintaining the strict confidentiality of my user ID and password and not allow another person to use my user ID to access the Services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation.

I understand that there will be no recording of any of the online session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.

I understand that I am not allowed to do any recording, screenshots, etc. of any kind, of any session, and are grounds for termination of the client-therapist relationship.

I further agree not to hold the provider liable for any electronic messaging charges or fees generated by my provider. I further agree that in the event my cell phone number and or cell provider changes, I will inform my provider.

I provide full informed consent to using technology in my treatment in accordance with these statements. I understand the risks associated with using technology in my treatment.

Your information will be encrypted.

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