AUTHORITY TO CONSENT: I certify that I have the legal authority to consent to treatment, medication, release of information, and all legal issues involving the above-named client. If my status as legal guardian should change, I will Immediately notify the practice of the name, address, and telephone number of the person who has assumed guardianship of the above-named client. I consent for the above-named client to participate in mental health assessment, treatment through our agency. I understand that I may revoke consent for the above at any time; however, I cannot revoke consent for action that has already been taken.
CONSENT LOCATION - I authorize and give consent for the above named individual to participate in mental health and behavioral health services and treatment through our agency at the following locations or settings: HOME, COMMUNITY, SCHOOL, TELEHEALTH, as appropriate and determined by the client.
TELEHEALTH & EMAIL CONSENT - If checked above, I understand and agree to receive telemental health services from my therapist. This means that my therapist and I will, through a live interactive video connection, meet for scheduled psychotherapy sessions under the conditions outlined in this document. I understand the potential risks of telemental health, which may include the following: 1) the video connection may not work, or it may stop working during a session; 2) the video or audio transmission may not be clear; and 3) I may be asked to go to my therapist’s office in person if it is determined that telemental health is not an appropriate method of treatment for me. I recognize the benefits of telemental health, which may include the following: 1) reduced cost and time commitment for treatment due to the elimination of travel; 2) ability to receive services near my home or from my home; and 3) access to services that are not available in my geographic area.
I understand that my therapist will make all efforts to use a HIPAA-compliant technology to transmit and receive video and audio and stores all notes and information related to my treatment in a manner that is compliant with state and federal laws. I also understand that, due to COVID-19, some video platforms and all telephone platforms are not HIPAA compliant. I understand that it is my responsibility to ensure that my physical location during videoconferencing is free of other people to ensure my confidentiality. Furthermore, I understand that recording my sessions is prohibited. I understand that I have the option to request in-person treatment at any time, and my therapist will assist in scheduling this or make a referral if travel to the therapist’s office is not feasible for me. I understand that closer providers may not be available depending on my location. I understand the limitations to confidentiality with my therapist include reasonable belief that I am a danger to myself or others. I understand that, if my therapist reasonably believes that I plan to harm myself or someone else, my therapist will contact local emergency services to come to my location and ensure my safety. I consent that at limited times, information may be shared by email between agency staff for treatment purposes only.
THIS CONSENT EXPIRES 2 YEARS FROM THE DATE SIGNED.
A copy of this form shall be considered equally as valid as the original.