Telehealth Informed Consent
Telehealth allows psychotherapy and other appropriate services to be provided when the client and therapist are in different locations through secure video, telephone, or other electronic communication.
Please review the following information carefully before participating in telehealth services.
Nature of Telehealth
I understand that telehealth services may include psychotherapy, consultation, or other appropriate clinical services provided through electronic communication rather than in person.
Telehealth is intended to provide access to care while maintaining the professional standards that apply to appropriate in-person services. I understand that telehealth may not be appropriate for every client, condition, or situation.
Benefits & Limitations
Potential benefits may include convenience, continuity of care, and increased access to services.
I understand that telehealth also has limitations and potential risks, including technology problems, interruptions in communication, reduced access to certain nonverbal or environmental information, privacy risks associated with electronic communication, and the possibility that telehealth may not be clinically appropriate in every circumstance.
Privacy & Confidentiality
Privacy and confidentiality remain important during telehealth sessions and are protected in accordance with applicable law and professional ethical standards. However, no electronic communication system can be guaranteed to be completely secure.
I agree to participate from a location that is reasonably private and appropriate for therapy whenever possible. I will inform my therapist if another person is present or able to hear the session.
Location During Telehealth Sessions
My therapist may ask me to confirm my physical location at the beginning of a telehealth session when needed for emergency planning or clinical safety.
I understand that I should inform my therapist if I am participating from a location different from my usual residence and that my therapist must comply with applicable licensing laws regarding where I am physically located during treatment.
Emergencies & Safety
Insights Wellness Center is not a 24-hour emergency or crisis service.
For an immediate or life-threatening emergency, I should call 911 or go to the nearest emergency department. For a mental health or emotional crisis, I may also call or text 988.
For safety purposes, Insights Wellness Center may maintain an emergency contact and other information reasonably necessary to respond to an emergency occurring during a telehealth session.
Technology Failure
If a session is interrupted because of a technology or connection problem, my therapist may attempt to reconnect with me or contact me by telephone or another previously agreed-upon method.
If we are unable to reconnect, we may continue by telephone, reschedule the remaining time, or make another appropriate arrangement.
Recording of Sessions
Telehealth sessions may not be audio-recorded, video-recorded, photographed, screen-recorded, or otherwise captured by either the client or therapist without prior knowledge and mutual written consent.
Communication Between Sessions
Text messages, voicemail, and email should generally be used for scheduling and brief administrative communication rather than ongoing psychotherapy. Electronic communication should not be used for emergencies.
Client Choice
Participation in telehealth is voluntary. I may ask questions at any time and may discuss whether in-person services are available or more appropriate.
I may withdraw my consent to participate in telehealth services at any time. Withdrawal of consent will not affect services already provided.
Acknowledgment & Consent
By signing below, I acknowledge that I have read and understand the information above, have had an opportunity to ask questions, and understand the potential benefits, limitations, privacy considerations, and risks associated with telehealth.
I understand the emergency and technology procedures described above and voluntarily consent to receive appropriate services from Insights Wellness Center, LLC through telehealth.
Typing my name electronically and submitting this form serves as my electronic signature and consent to participate in telehealth services.
