Teletherapy Consent Form

TELETHERAPY CONSENT FORM

It is my expectation that you will benefit from online therapy as all or part of your psychotherapy, but there is no guarantee. Therapy is conducted using interactive audio and video. Online based services as care may not be appropriate for your needs. If I assess that face to face is more appropriate, I will offer an appointment or provide referrals.

Confidentiality: The information disclosed during the course of my therapy is confidential, however, there are legal exceptions both mandatory, and permissible, including a child, elder, and dependent adult abuse; threats
of harm to self or others, or if court-ordered. The therapist will take all precautions to ensure online therapy is confidential, but the client is informed that transmission could possibly be disturbed or distorted by technical
failures, or interrupted or accessed by unauthorized persons.

Appointments and Charges for Services: Patients are responsible for checking with their insurance to verify that Teletherapy Health therapy is covered. Copayment, deductible, and fees not covered by insurance are the client’s responsibility and are due at the time of service.

Limitations: On-line therapy plays a useful role in addressing mental health issues. It also has inherent limitations in not being physically present. For instance, body language is limited by this format and technical
difficulties can have poor timing. Due to these limitations, this method is not recommended when in a state of crisis or when at high risk.

When should I seek traditional mental health treatment rather than internet therapy?

1. If you are having thoughts of harming yourself and or someone else. Please call 911.
2. If you are in an abusive or violent relationship
3. If you have been seriously depressed
4. If you have serious substance abuse dependence
5. If you are a minor (under 18 years old)

Procedures should we encounter technical difficulties or disruptions in service: It is understood that when communicating by internet or other electronic means, disruptions in service or other technical difficulties will likely occur from time to time. Should a disruption occur at a time of crisis, the patient agrees to immediately phone their therapist.

Disclaimer :

By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature I on this document.