Consent for Telehealth Consultation

Telehealth Services:

To use telehealth, you need an internet connection and a device with a camera for video. I, the clinician, Jooyoung Kim, LPCC, can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, I will recommend a different option. There are some risks and benefits to using telehealth: 

Risks

  • Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. I carefully vet any telehealth platform to ensure your information is secured to the appropriate standards.

  • Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, I will follow the backup plan that you agree to prior to sessions.

  • Crisis Management. It may be difficult for me to provide immediate support during an emergency or crisis. You and I will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services. 

Benefits

  • Flexibility. You can attend therapy wherever is convenient for you.

  • Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.

Recommendations

  • Make sure that other people cannot hear your conversation or see your screen during sessions.

  • Do not use video or audio to record your session unless you ask me for permission in advance.

  • Make sure to let me know if you are not in your usual location before starting any telehealth session.

Consent for Telehealth Consultation:

  1. I understand that my clinician wishes me to engage in a telehealth consultation.

  2. My clinician explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/clinician  visit due to the fact that I will not be in the same room as my clinician, Jooyoung Kim, LPCC. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

  3. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.

  4. I understand that my clinician or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

  5. I have had a direct conversation with my clinician, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

Consent to Use the Telehealth By TherapyNotes:

  1. Telehealth by TherapyNotes is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge: Telehealth by TherapyNotes is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

  2. Though my clinician and I may be in direct, virtual contact through the Telehealth Service, neither TherapyNotes nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

  3. The Telehealth by TherapyNotes Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

  4. I do not assume that my clinician has access to any or all of the technical information in the Telehealth by TherapyNotes Service – or that such information is current, accurate or up-to-date. I will not rely on my clinician to have any of this information in the Telehealth by TherapyNotes Service.

  5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.