I consent to teletherapy, which is a form of psychotherapy service provided via Internet technology, which can include treatment, emails, texts, and telephone conversations through video, or data communications.
I also understand that teletherapy involves the communication of my medical/mental health information, both orally and visually.
Teletherapy has the same purpose or intention as psychotherapy sessions that are conducted in person. However, due to the nature of the technology used, I understand that teletherapy may be experienced somewhat differently than face-to-face treatment sessions.
Client’s Rights, Risks, and Responsibilities
I understand that I have the following rights with respect to teletherapy:
1. I, the client, am a resident of California.
2. I, the client, have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
3. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy is confidential. However, there are mandatory exceptions to confidentiality, which are described in the general Consent Form I received at the start of treatment.
4. I understand that there are risks and consequences of participating in teletherapy, including, but not limited to, the possibility – despite best efforts to ensure high encryption and secure technology on the part of my therapist – that: the transmission of my information could be disrupted or distorted by technical failures, interrupted by unauthorized persons, and the electronic storage of my medical information could be accessed by unauthorized persons.
5. There is a risk that services could be disrupted or distorted by unforeseen technical problems.
6. In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services. I also understand that if my therapist believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I have the right to discuss this with my therapist.
7. I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may not improve, and in some cases may even get worse.
8. I accept that teletherapy 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. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.8255 for free 24 hour hotline support. Clients who are actively at risk of harm to self or others are not suitable for teletherapy services. If this is the case or becomes the case in future, my therapist will recommend more appropriate services.
9. I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in teletherapy. I am responsible for (1) providing the necessary computer, internet access, and/or phone for my teletherapy sessions, and (2) arranging a location with sufficient privacy that is free from distractions or intrusions for my teletherapy session. It is the responsibility of the therapist to do the same.
10. I understand that dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.