Consent Forms

General Information

Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by both therapist and client(s). As a client in psychotherapy, you have certain rights that are important for you to know. There are also certain limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you. This document reviews those rights, limitations, and responsibilities. When you sign this document, it will represent an agreement between us.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. Psychotherapy is a process, and is not easily described in general statements. What it involves varies depending on the personalities of the therapist and client(s), and the particular issues you hope to address. There are many different methods I may use to deal with those issues. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But, there are no guarantees as to what you will experience.

Confidentiality

In general, the privacy of all communications between a client(s) and a therapist is protected by law, and I can only release information about our work to others with your written permission.  There are a few exceptions, however. In the following instances a therapist may release information without permission, in order to keep clients and others safe, and to abide by law:

  1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
  2. If a client threatens grave bodily harm or death to another person.
  3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
  4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
  5. Suspected neglect of the parties named in items #3 and #4.
  6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
  7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client(s). The consultant is also legally bound to keep the information confidential. Ordinarily, I will not tell you about these consultations unless I believe that it is important to our work together.

If we happen to see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

This document is intended to inform you of the benefits, risks and alternatives associated with telehealth therapy services to be provided by Therapy Service Providers on the Choosing Therapy technology platform. Your understanding of telehealth therapy is important prior to participation. Please carefully review the information below.

What is Telehealth Therapy?

‘Telehealth Therapy’ is a method for providing behavioral health services, including psychotherapy, using an interactive telecommunications system (e.g., the internet or telephone) by a practitioner who is licensed under state law to provide such behavioral health services to a patient in a remote location.  Telehealth Therapy uses electronic communications to enable a patient to share information with a healthcare practitioner in order to allow him or her to provide care and treatment in accordance with the practitioner’s scope of practice.

Potential Benefits

Telehealth Therapy provides improved access to behavioral healthcare services and time flexibility, and increased patient access to experts who may not be available for a face-to-face consultation. Telehealth Therapy also allows for efficient and prompt evaluations, consultations, diagnoses, and treatment, leading to improved access to healthcare. Telehealth Therapy conducted on Choosing Therapy’s platform also provides HIPAA-compliant and secure communication methods, as opposed to other non-secure video conferencing apps.

Psychotherapy has been shown to have numerous benefits for individuals. Specifically, therapy often leads to a reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. However, there are no guarantees about the results or outcomes of therapy and its process.

Potential Risks

Telehealth Therapy offers an efficient way for practitioners and patients to communicate.  However, there are potential risks associated with the use of telehealth services, including without limitation:

  • Delayed care due to telecommunication equipment failures or information transmission errors (e.g., poor image quality);
  • The possibility that the transmission of your health information could be disrupted or distorted by technical failures;
  • Risks related to a patient withholding key medical information or records; or
  • Unauthorized access of protected health information (PHI) as a result of cyber security or other security breaches.

Psychotherapy also has its own associated risks, which may include, but are not limited to, experiencing uncomfortable feelings, such as sadness, guilt, anger, frustration, loneliness and helplessness. The process of psychotherapy often requires discussing unpleasant aspects of your life. Making changes in your life can be disruptive to the relationships you already have. It is important to assess all of the risks prior to proceeding with Telehealth Therapy.

Do I Have to Use Telehealth?

Use of Telehealth Therapy is voluntary and not required. You may always seek traditional, face-to-face healthcare as an alternative to Telehealth Therapy (e.g., face-to-face consultations with, or examinations by, a care provider).

Indemnification

You agree to indemnify and hold harmless Choosing Therapy and its shareholders, officers, directors, employees, representatives, agents, and successors from and against any and all loss, damage, expense, liability, claims, or demands brought by any party whatsoever, arising out of or related to any failure of technology or equipment in connection with the provision of Telehealth Therapy, whether or not any such loss, damage, expense, liability, claim, or demand arises from or relates to Choosing Therapy’s negligence.

Follow-up Care; Emergency Situations

If you are experiencing a medical emergency, call 911 or seek care at an emergency room facility or other provider equipped to deliver urgent care.

If there is an urgent situation in which you experience an adverse reaction, or technical difficulties preventing you from communicating with the Telehealth Therapy practitioner, or if you no longer wish to use the Telehealth Therapy services, immediately stop using the Telehealth Therapy services and contact Choosing Therapy at [email protected]

Acknowledgement

By signing this form, you acknowledge that you have read this Consent and understand the risks, benefits, and alternatives of participating in Telehealth Therapy and have been given ample opportunity to ask questions which have been answered to your satisfaction. You further acknowledge and understand that:

  • You will need to provide a full and accurate medical history, including any pre-existing health conditions, so that your practitioner can determine a treatment plan.
  • Your Telehealth Therapy practitioner will determine whether Telehealth Therapy is appropriate for you based on your specific condition and needs.
  • Results are not guaranteed, and you may or may not benefit from the Telehealth Therapy services.
  • You will be informed of any charges associated with the Telehealth Therapy services prior to incurring any charges and you agree that you are responsible for paying the full amount of all costs associated with the Telehealth Therapy services provided to you.
  • You may not submit a claim to Medicare, Medicaid, any other federal payor, or any state or private insurer regarding any fees for the Telehealth Therapy services rendered to you.

Consent to Use the Telehealth by SimplePractice and Choosing Therapy

Choosing Therapy uses telehealth technology by SimplePractice to support Choosing Therapy’s technology platform, allowing Telehealth Therapy practitioners to conduct telehealth videoconferencing appointments. By signing this document, I acknowledge:

  1. Telehealth by SimplePractice and Choosing Therapy is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
  2. Though my Telehealth Therapy practitioner and I may be in direct, virtual contact through the Choosing Therapy and SimplePractice technology, neither SimplePractice nor Choosing Therapy provides any medical or behavioral health services or advice including, but not limited to, emergency or urgent healthcare services.
  3. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

BY CLICKING ON THE CHECKBOX BELOW, I AM PROVIDING MY ELECTRONIC SIGNATURE AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

This page was last updated on 8.27.2020.