Tele Mental Health Informed Consent

TRINITY PSYCH WELLNESS

Tele Mental Health Informed Consent.
Please review and indicate you have understood each content section.

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Last Name

INTENDED USE: I have read and understand the content below. This form is provided as an additional consent and will be added to your file along with your initial paperwork which includes treatment consent and practice policies. This form is used when the therapist or medication prescriber and the client have determined that online visits are a necessary and supportive service for the client’s treatment. All telehealth visits will be billed in the same manner as an in-person office visit, unless otherwise stipulated by your insurance.

Yes

What Is Tele Mental Health: have read and understand the content below. Telehealth is the use of technology, like video conferencing software, to provide services at a distance. Your treatment will be provided through interactive audio, video, and/or telephone communication. Telehealth by Microsoft Teams is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use, and you will receive an email prior to the visit with “invite” or link to the session. It is 100% HIPAA compliant, and secure. NOTE: Telehealth via Microsoft Teams is NOT an Emergency Service and in the event of an emergency, please phone 9-1-1, or 988 for the Suicide and Crisis Hotline.

Yes

Benefits Risks: I have read and understand the content below. There are several benefits to using telehealth services such as increased accessibility to treatment, reduced travel time, participation in therapy or medication management in an environment of your choosing, mutual protection from colds and other viruses, and the ability to continue regular visits if you are injured or must care for a child or an injured/ill family member. Years of empirical research has established tele mental healthcare as a useful and effective mode of healthcare delivery. When using technology, however, there is a risk of security and technical difficulties, such as disconnection of internet, computer or software malfunctions, etc. Additionally, technical issues can sometimes impact or limit visual or auditory cues and can contribute to miscommunication or misunderstanding. Please know that open, clear, and meaningful communication is one of our highest priorities. Please let your provider know about any communication challenges or perceived misunderstandings during your visit. If issues persist and impact your treatment, we will discuss alternatives and consider switching to in-person or phone (if allowed by your insurance) visits. Please do not share the telehealth appointment invite/link that you receive with anyone unauthorized to attend the appointment.

Yes

Advisability Of In-Person Evaluation: I have read and understand the content below. Telehealth is not appropriate for all clients. Some practitioners prefer an in-person intake meeting to determine whether tele mental health meets your needs. Should tele mental health become unhelpful or otherwise interfere with your meeting your treatment goals, we can discuss other alternatives, such as in-person visits.

Yes

Privacy & Confidentiality: I have read and understand the content below.The laws that protect your privacy and the confidentiality of your health information also apply to telehealth services. As with in-person visits, your protected health information can only be shared with outside parties if you give written consent via a Release of Information, or there is a court order signed by a judge. Additionally, if you have a substance use disorder, this information will not be included in your chart without your written consent. Also similar to in-person visits, you do not have direct access to your electronic medical record or to the prescription drug monitoring program – please speak to your provider or prescriber if you have questions. For more information about exceptions to confidentiality, please refer to the Notice of Privacy Practices and the Treatment Consent.

Yes

Video & Recordings: I have read and understand the content below. No permanent video or voice recordings are kept from our telehealth sessions. To protect and preserve your privacy and confidentiality, it is also advised that you do not record or store videoconference or phone sessions.

Yes

Location: I have read and understand the content below. For safety and licensing reasons, you will be asked at the start of your visit to identify your current location. Please note that we cannot provide services while you are driving a car (you may sit in a stationary car and have the visit, however), or if you are in an out-of-state location unless your provider is also licensed in that location. For that reason, please let us know if you anticipate traveling or changing locations so that we may assist with appropriate arrangements or referrals.

Yes

Emergency Contact: I have read and understand the content below. We ask on our paperwork for an emergency contact person of your choosing. This person will only be contacted in case of emergency, and therefore must be at least 18 years old and able to get to your location in the event that is needed. Alternatively, and depending on the nature of the emergency, we might call local authorities or 9-1-1 on your behalf. If you did not supply the emergency contact person and their information in the paperwork, your therapist or medication provider will ask for it in the first visit.

Yes

Bring Someone to Session: I have read and understand the content below. If you would like to have a family member or other person in the session with you, please discuss that ahead of time. It may not be therapeutically appropriate, or different arrangements might need to be made.

Yes

Technical Difficulties: I have read and understand the content below. If the reception is bad, or if the visit gets disconnected, your provider will try to reconnect by restarting the video platform (Microsoft Teams). If there are still difficulties, a phone session (if allowed by your insurance) may be offered, along with the option to cancel and reschedule the appointment.

Yes

Consent for Tele Mental Health Visits: I have read and understand the content below. I have read and understand the information provided above regarding telehealth, its risks, and its benefits. My therapist or medication prescriber will get my verbal consent to engage in telehealth services and will document that in my medical record. I understand that I have the right to withhold or withdraw this consent to the use of telehealth at any time, without affecting my right to future care or treatment.

Yes

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