Telemental Health Informed Consent

_____________________________________

, hereby consent to participate in telemental health with,

______________________________________________ , as part of my psychotherapy. I understand that

telemental health 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 located in two different locations.

I understand the following with respect to telemental health:

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.

I understand that there are risks, benefits, and consequences associated with telemental health,

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 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.

I understand that the privacy laws that protect the confidentiality of my protected health information

(PHI) also apply to telemental health 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).

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 telemental health services are not appropriate and a higher level of care is required.

I understand that during a telemental health session, we could encounter technical difficulties

resulting in service interruptions. If this occurs, end and restart the session. If we are unable to

to discuss since we may

reconnect within ten minutes, please call me at_________________

___

have to re-schedule.

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 you are at the beginning of each session. I also need a contact person who I may contact on

your behalf in a 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.

In case of an emergency, my location is: __________________________________________

and my emergency contact person’s name, address, phone: ____________________________

____________________________________________________________________________

I have read the information provided above and discussed it with my therapist. I understand

the information contained in this form and all of my questions have been answered to my

satisfaction.

Signature of client/parent/legal guardian Date

Signature of therapist Date

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members and online readers should not act based on the information provided in the LDF Web site. Laws and

court interpretations change frequently. Legal advice must be tailored to the specific facts and circumstances of

a particular case. Nothing reported herein should be used as a substitute for the advice of competent

counsel.