(name of client) hereby consent to participate in Telehealth with.
Clarillette Heredia, LMFT as part of my psychotherapy. I understand that Telehealth is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are in two separate locations.
I understand the following with respect to Telehealth:
1. I understand that if 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.
2. I understand that there are risk and consequences associated with Telehealth, including but not limited to, disruption of transmission by technology failures, interruption and /or breach of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. To limit any potential breach of confidentiality, we will utilize a HIPPA compliant video platform called Zoom. (This consent will also cover telephonic sessions without the use of video technology.) Other compliant platforms used: Google Meet, FaceTime and Psychology Today video (selection will depend on the client’s preference).
3. 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 disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
4. 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, clear intent to harm oneself or someone else, court order from a judge).
5. 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.
6. I understand that during a Telehealth session, we could encounter technical difficulties resulting service interruptions. If this occurs, end and restart the session. If we are unable to reconnect withing ten (10) minutes, please call me at 813.943.8111 to discuss the possibility we may have to re-schedule.
7. I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
Emergency Protocols
I need to know your location in case of an emergency. You agree to inform me of the address where are at the beginning of each session. I also need a contact person who I may contact on your behalf in the life-threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.
