Online therapy consent

Online Therapy and Limitations

I understand that online therapy includes the practice of therapy delivery, diagnosis, consultation, treatment, and education using interactive audio and video communication. I understand that phone and online sessions have limitations compared to in-person sessions.I understand telehealth based services may or may not be reimbursable by health insurance. I understand online therapy is not appropriate if I am experiencing crisis or having suicidal or homicidal thoughts. Should crisis occur, I agree to call 911, go to the nearest emergency room, or contact a crisis hotline.

Procedures for Technical Difficulties or Internet Disruptions

I understand that online therapy is technical in nature and that problems with the Internet may occur. If something beyond our control disrupts the connectivity of our session, the therapist will immediately try to video call me again. If the video call is unsuccessful, the therapist will call me and the session will be completed via phone.

Termination of Services

During the first few sessions, the therapist will assess if online therapy is the best medium for providing me counseling services. If online therapy is deemed inappropriate, the therapist will suggest face-to-face therapy. When face-to-face is not possible, the therapist will  provide me with direction on how to find another qualified provider in my area. 

Confidentiality

Because online therapy utilizes the Internet for the transmission of personal information I understand the therapist cannot guarantee confidentiality of the personal information I provide via this form of communication. However, any information that I provide to the therapist will subsequently remain confidential and will not be given to a third party unless I give specific permission to release the information, or the therapist is required to do so by law. The issue of confidentiality is further governed by both law and ethics. 

By law I hold the privilege of confidentiality and the therapist will not release any information to anyone without my written permission, or a court order. There are some exceptions to my rights under the law. Examples include, but are not limited to, when the therapist has reasonable cause to believe that I am a danger to myself or another person. The therapist is also required by law to report any information about or reasonable suspicion of sexual, physical or emotional abuse of minors or elders to Child Protective Services or Adult Protective Services. I understand that if I have any concerns regarding confidentiality issues, I should speak with my therapist about these and other exceptions to the confidentiality privilege and her responsibility concerning them.

Harm to Self or Others

If there is an emergency during our work together where the therapist is concerned about my personal safety, the possibility of me injuring someone else or about my receiving proper psychiatric care, I understand the therapist will do whatever she can within the limits of the law to prevent me from injuring myself or others and to ensure that I receive the proper medical care. For this purpose, the therapist may also contact law enforcement, hospital or an emergency contact whose name I have provided.

Release Agreement

I understand that the therapist does not bill insurance directly and that each session must be paid for at the time of service. I hereby authorize the therapist to furnish my designated insurance carrier all information concerning my diagnosis and course of treatment, if it is requested. I understand that extensive casework involving provision of information to my insurance company may be billed at the therapist's hourly rate. I understand I am responsible for all charges.

Payment Agreement

I will provide a valid credit card to be kept on file and agree to be charged at the time of each session. 

Late Cancellation/Missed Appointments

I understand that if I cancel, no-show, or reschedule my appointment less than 24 hours before my scheduled appointment, my credit card held on file will be charged the entire fee of the missed session.