Your health is our top priority.
By checking the box to this form you hereby consent to participate in Telemental health with a Therapist on the Platform, as part of your psychotherapy. You understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a Therapist practitioner and a client who are located in two different locations.
You understand the following with respect to telemental health:
1) You understand that you have the right to withdraw consent at any time without affecting your right to future care, services, or program benefits to which you would otherwise be entitled.
2) You 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.
3) You 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.
5) You understand that if you are 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.
6) You understand that during a telemental health session, the Therapist could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If the Therapist or you are unable to reconnect within ten minutes, please call Total Life at 1-800-567-4322 (LIFE) or email [email protected] to re-schedule.
7) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
Please ensure you tell the Therapist your location at the start of each session in case of an emergency. You agree to inform the Therapist of the address where you are at the beginning of each session. Please also ensure you provide a contact person during the initial intake session who the Therapist 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. It is your responsibility to update the Therapist if this contact person changes.
I have read the information provided above and understand that I can discuss it with my Therapist during the session at anytime or I can email [email protected] or call 1-800-567-LIFE prior to using the Platform. By using the Platform, I understand the information contained in this form and all of my questions have been answered to my satisfaction.