1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
2. The laws that protect the confidentiality of my medical information also apply to online counseling/tele-therapy. As such, I understand that the information disclosed by me during the corse of my therapy or consultation is generally confidential. However, there are limits and exceptions to confidentiality with tele-therapy, just as there are with in-person therapy. I am in agreement with these limits/exceptions, and understand that my therapist will explain these to me in detail if I wish.
3. I understand that there are risks and consequences from online counseling/tele-therapy, including, but not limited to, the possibility, despite reasonable efforts on the part of the THERAPIST that: the transmission of my information cold be disrupted or distorted by technical failures.
** I understand that if the tele-therapy session does get disconnected, THERAPIST will call me back by phone to complete our session. If my therapist feels there is an emergency and I do not answer my given number my therapist may call my emergency number to verify I am okay.
4. In addition, I understand that online counseling/tele-therapy based services and care may not be as complete as face-to-face services. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and efforts of my counselor, my condition may not improve, and in some cases my even get worse.
5. I understand that I may benefit from online counseling/tele-therapy, but that results cannot be guaranteed or assured.
6. I accept that online counseling/ tele-therapy does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911; or proceed to the nearest hospital emergency room for help; or call my primary care physician or psychiatrist. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support.
7. I understand I am responsible for (a) providing the necessary computer, telecommunications equipment and internet access for my online counseling/ tele-therapy sessions, and (b) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my/my child's online counseling/ tele-therapy session.
8. I understand that i have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law.
I have read, understand and agree to the information provided above.