Teletherapy Informed Consent - Cindy Lerner Counseling

I,*

First Last

hereby consent to participate in teletherapy with Cindy Lerner, Ph.D, LCSW, as part of my psychotherapy. I understand that teletherapy is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand the following with respect to teletherapy:

1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

2) I understand that there are risks, benefits, and consequences associated with teletherapy, 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) I 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.

4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to teletherapy unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health in a legal proceeding).

5) I understand that if I am 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 teletherapy services are not appropriate and a higher level of care may be required.

6) I understand that during a teletherapy session,we could encounter technical difficulties resulting in service interruptions. If this occurs, the therapist may end and restart the session. If we are unable to reconnect within 10 minutes, please Email me at this address, to discuss, since we may have to reschedule the session:

Email*

7) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

Emergency Protocols

I understand that you need to know my location in case of an emergency. I agree to inform you of the address where I am at the beginning of each session. I also understand that you need a contact person who you may contact on my behalf in case of a life-threatening emergency only. This person will only be contacted to go to my location or take me to the hospital in the event of an emergency.

In the event of an emergency, my location is:

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

and my emergency contact person's information is:

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email

I have read the information provided above and have had the opportunity to discuss it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.

BY ENTERING MY NAME BELOW, I AM INDICATING MY INTENT TO ELECTRONICALLY SIGN THIS AGREEMENT AND I REPRESENT THAT BY SUBMITTING THIS DOCUMENT I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL TERMS HEREIN.

Please Email a copy to me.*

Yes, please send a copy.
No, thank you.

Name

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