I hereby give my consent to participate in telehealth services provided by Counseling Made Easy. I understand that telehealth is the practice of delivering clinical health care services via technology assisted media or other electronic means between a provider and a client who are in two different locations. I understand that the primary difference between telehealth and direct, in-person service delivery is the inability of the provider to have direct, physical contact with the client.
I understand the following with respect to telehealth:
a. I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
b. I understand that there are risks, benefits, and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. I understand that the quality of the transmitted data may affect the quality of the services provided by the provider.
c. I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
d. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e., mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
e. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate, and a higher level of care is required.
f. I understand that during a telehealth video session, we could encounter technical difficulties resulting in service interruptions. If this occurs, Counseling Made Easy will restart the session. If Counseling Made Easy is unable to reconnect within a reasonable amount of time, Counseling Made Easy will call me at the number I have provided to discuss how to proceed (re-schedule, switch to another video platform, or switch from video to phone).
g. I understand that to protect my privacy I need to choose a private location from which to conduct telehealth. I understand that if I am participating in a video telehealth call, I should ensure an appropriate call environment by taking care that the camera is positioned on a secure and stable surface to avoid shaking and that I am appropriately positioned in front of the camera, so that my face is clearly visible to my provider.
h. I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency. I understand that at the beginning of each session I am to inform Counseling Made Easy of the address of my location.
i. I understand that if I have any questions about the written information provided above, or need clarification, I can contact Counseling Made Easy by using the messaging function on the online client portal or the contact page of the website (www.counseling-made-easy.com), by sending an email to support@counseling-made-easy.com, or by calling Counseling Made Easy at 301-804-1892.
I certify that I have read and understood the written information provided above, have been provided with the opportunity to ask questions or seek further clarification, and, if I had any questions, I have had all answered to my satisfaction. I further certify that I am agreeing to conduct transactions electronically, and that by checking the box I am electronically signing this informed consent and intend for my signature to be binding on myself. I understand that I can print a copy of this Agreement and may also request a paper copy using the contact information provided above.