Agreement to Telehealth

In the event of unforeseen circumstances that would prohibit meeting face-to-face for a scheduled appointment, an option would be Telehealth for the purpose of continuity of contact. The Telehealth platform would be confidential and meet ethical and legal standards. If you would be open to considering this option, please read and sign this agreement.

I understand these are my rights under this agreement:

• I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. Any information disclosed by me during the course of my therapy is confidential.
• By law, there are exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse, and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my therapist has the right to break confidentiality. I understand that the publication of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur.
• I understand that there are risks unique and specific to Telehealth, including but not limited to the possibility that our therapy sessions or other communication regarding my treatment could be disrupted or distorted by technical failures, could be interrupted, or could be accessed by unauthorized persons.

I have read and understand the information provided above. I have the right to discuss any of this information with my therapist and to have any questions I may have regarding my treatment answered to my satisfaction.

I understand that I can withdraw my consent to Telehealth communications by providing written notification to Tzippy Farhy Psychotherapy, LLC. By checking the box below and typing my full name, I indicate that I have read this Agreement and agree to the terms.