Consent for Telehealth Services

The Digital Age continues to facilitate new ways to assist people in meeting their mental health needs. We are happy to keep pace with technological advancements and provide telehealth services. As part of our commitment to your well-being and safety, we have established some guidelines. Please review this carefully.

TELEHEALTH: Variously dubbed telemedicine, teletherapy, distance therapy, e-therapy, internet therapy, or online therapy, “telehealth” is defined as the use of electronic transmission to provide interactive, real-time mental health services remotely, including consultation, assessment, diagnosis, treatment planning, counseling, psychotherapy, coaching, guidance, psychoeducation, education, and transfer of medical information with an experienced therapist. This can include both video and audio communication via the internet or telephone. Telehealth services do not include texting or e-mail.

OFFICE AGREEMENTS: Telehealth is governed by the same ethics and laws that apply to in-person, in-office psychotherapy. Consequently, all other policies, consents, and agreements signed with your therapist also apply to telehealth services. This document is an addendum to all in-office services agreements and does not substitute for any such agreements. Professional services are being provided under a license issued by and limited to practice within the state of California. Therefore, the client signing below affirms that they reside in the state of California at the time of telehealth services.

SCHEDULING & PAYMENT: Telehealth sessions are scheduled in advance at regular times. These appointments reserve time specifically for you. Just as with in-person appointments, you are responsible for keeping and paying for all telehealth appointments. We will start and end on time. In all telehealth sessions, the therapist will initiate the telehealth session unless other arrangements are made in advance. A 15-minute window will remain open after your session's start time. As with an in-person session, if your therapist doesn't hear from you or can’t reach you, please call them by phone if you are having difficulty. Cancellations and missed appointments are handled the same way as in-person cancellations. The therapist cannot be responsible for the client’s ability to participate in sessions, including technological difficulties or disruptions.

CONFIDENTIALITY: The same laws protecting the confidentiality of your medical information in the office apply to telehealth sessions, including mandatory reporting and permitted exceptions, such as child, elder, and dependent adult abuse reporting, risks to the client’s well-being, threats of violence to an identifiable victim, and when clients enter their own emotional or mental factors into a legal proceeding. The client and therapist both agree to keep the same privacy safeguards used during in-person sessions. Ensure that your environment is free from unexpected or unauthorized intrusions or disruptions to our communication. You are asked to preserve privacy and limit the risk of being overheard by a third party by conducting the session in a private room with closed doors, with reasonable sound barriers, and no one else present or observing. Earphones may be helpful as well. The client and therapist both agree not to record the telehealth sessions without prior written consent.

CONSENT: You have the right to opt in or opt out of telehealth communication at any time, without affecting your right to future care or treatment, except during the COVID-19 pandemic, when in-person sessions will not be available for a period of time. Please discuss this thoroughly with your therapist. Your signature below indicates that you understand you are responsible for learning to handle the specific medium used prior to your telehealth sessions and for engaging in any necessary rehearsals to ensure effectiveness. Before an initial telehealth session, a test call of up to 10 minutes can be arranged to ensure that the technology is functioning properly.

SECURITY: No electronic transmission system is considered completely safe from intrusion. While a variety of software programs are available for video conferencing, such as Skype, FaceTime, or GoToMeeting, not all are encrypted or compliant with Federal law to protect the privacy of your health communication. We use software with encryption to maximize your confidentiality. Interception of communication by third parties remains technically possible. You are responsible for information security on your own computer, laptop, tablet, or smartphone. Due to the complexities of electronic media and the internet, the risks of telehealth include the potential for the release of private information, such as audio, written materials, and images, which may be disrupted, distorted, interrupted, or intercepted by unauthorized persons, despite your therapist’s reasonable efforts. Consequently, your psychotherapist cannot fully guarantee the security of telehealth sessions.

TELEPHONE: Telehealth can include telephone sessions. When using the telephone, remember to secure your privacy so you feel comfortable speaking about personal and private matters. If using a cell phone, remember that not all calls or telephones are absolutely secure and may be compromised by various detection devices.

VIDEO CONFERENCING: The client is responsible for their own hardware and software, audio and video peripherals, and connectivity and bandwidth considerations. At the time of the telehealth appointment, it is your responsibility to have your electronic device on, video conferencing software launched, and be ready to start the session. This requires setting up a few minutes prior to the start time. If a video telehealth session is disrupted after reasonable attempts, we will switch to a telephone session instead.

PAYMENT & INSURANCE: Telehealth services are professional services and are charged at the same rate as in-person services. Clients relying on insurance reimbursement are responsible for contacting their insurance companies well in advance to ensure that telehealth is covered by their policy. Telehealth may be coded differently for insurance billing purposes. Even when health insurance covers in-person services, it may limit or deny coverage of telehealth services. If your insurance does not cover telehealth services, you will personally be responsible for full payment.