I consent to engaging in telehealth with:
The Counseling Shop and my provider, specifically, as a part of the therapy process and my
treatment goals. I understand that teletherapy psychotherapy may include mental health
evaluation, assessment, consultation, treatment planning and therapy. Telehealth will occur
primarily through interactive audio, video, telephone and/or other audio/video communications.
Technology: I understand that I will need to download an application and/or software to use
this platform. I also need to have a broadband Internet Connection or a smartphone device
with a good cellular connection at home or at the location deemed appropriate for services. I
understand I do need to take precautions on my end to ensure privacy in the setting I choose
to engage in telehealth appointments. I further understand my provider will be providing me a
link to a secure platform within doxy.me to engage in services and my provider will ensure
HIPAA compliance and security from the location they are engaging in services. All attempts to
keep information confidential while using this secured system will be made but a guarantee of
100% confidentiality cannot be made with inherent issues with the communication systems.
I also understand that in case of technology failure, I may contact my provider via phone to
coordinate alternative methods of treatment.
I understand that using the Telemedicine platform allows access to mental health services that
might not otherwise be available to me due to my mental health, and/or my physical, resource,
or geographic limitations.
Scheduling: I understand that scheduling is conducted through my provider and is based on
my provider’s normal clinic hours. Telemedicine appointments are considered outpatient
services and are not intended as a substitute for emergency or crisis services. Crisis or mental
health emergencies should be directed to the local county crisis line or dialing 911.
I understand I have the following rights with respect to telehealth:
In addition, I understand that telehealth based services and care may not be as complete as inperson services. I understand that if my therapist believes I would be better served by other
interventions, I will be referred to other mental health professionals who can provide those
services in my area. I also understand that there are potential risks and benefits associated
with any form of mental health treatment, and that despite my efforts and efforts of my
therapist, my condition may not improve, or may have potential to get worse.