Telehealth Consent

Information and Informed Consent for Telemental Health Treatment Telemental health is live two - way audio and/or video electronic communications that allows providers and clients/patients to meet outside of a physical office setting.

Client:

  • Understands that telemental health/medical services are completely voluntary and that you can withdraw this consent at any time.

  • Understands that none of the telemental/telemedicine health sessions will be recorded or photographed.

  • Understands not to make or allow audio or video recordings of any portion of the sessions.

  • Understands that the laws that protect privacy and the confidentiality of client information also apply to telemental health/telemedicine, and that no information obtained in the use of telemental health/telemedicine that identifies you will be disclosed to other entities without your consent.

  • Understands that telemental health/telemedicine is performed over a secure communication system.

  • Understands that any internet based communication is not 100 % guaranteed to be secure.

  • Understands that the provider/therapist and Company (THS) will not be held responsible if any outside party gains access to your personal information by bypassing the security measures of the communication system.

  • Understands there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.

  • Understands that you or your provider/therapist may discontinue the telemental/telemedicine sessions at any time if it is felt that the video technology is not adequate for the situation.

  • Understands that if there is an emergency during a telemental health/telemedicine session, then my therapist/provider may call emergency services and/ or my emergency contact.

  • Understands that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and that all office policies and procedures apply to telemental health/telemedicine services.

  • Understands that if the video conferencing connection drops while you are in a session, my therapist/provider will contact me back. During the evaluation process at times your therapist/provider will complete an evaluation over the phone. All therapists/providers who call from Teri's Health Services are held to the same practice procedures as in office providers/therapists. All providers/therpaists over telemental health/telemedicine services are mandated reporters by law. If your the client reports they might harm themselves or someone else or hang up the phone during session and you have stated risk of harm your therapists/providers is permitted by Arizona law to break confidentiality to get you help or someone else in foreseeable harms way. In addition, if you as the client/patient are in crisis and you hang up the phone and your therapist/provider is unable to contact again 911 or the nonemergency line will be contacted to respond for help.