I ______________________________________________________________ [name of client] hereby consent to engaging in telehealth with ExpectGreaThings Counseling. I understand that “telehealth” includes the practice of health care assessment, diagnosis, consultation, treatment and psychoeducation using interactive audio, video, or data communications. I understand that using the Telehealth platform allows me to have access to mental health services that might not otherwise be available to me due to a variety of circumstances.
Technology: I understand that I will be using Zoom a HIPAA compliant telehealth platform for my telehealth sessions as this platform protects data privacy by having all audio/video communication securely encrypted and transmitted from point-to-point. It is strongly advised that you make sure to consider the location of engaging in a telehealth session; preferably in a secure room without anyone else present to hear your conversation to help protect your privacy as you will discuss sensitive matters with your therapist. I understand that I will need to use the application invitation sent to me by my therapist and download it prior to the session (if a download is necessary). I understand that I will 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 also understand that in case of technology failure, I may contact my therapist via phone to coordinate alternative methods of treatment.
Financial Obligations: Fees associated with telehealth appointments are the same as “in office” appointments and are payable by PayPal and Venmo. The fee is $135 for 45/50 minute sessions.
Cancellations: I understand that the ExpectGreaThings Counseling’s 24 hour cancellation policy applies to telehealth, and I agree to pay for any appointment that I miss or cancel within that 24 hour window unless using one of the two exceptions (as outlined in the policy document). If there are technological issues on my side as a client, that I feel interrupt the service of my care, I may use one of my two exceptions for paying for the session. However, if the two exceptions have been used, I am responsible for the full fee of a 45/50 minute session.
Confidentiality: The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I understand that I have the following rights with respect to telehealth: 1. I have the right to withdraw my consent at any time. 2. I understand that there are risks and consequences associated with telehealth including, but not limited to the possibility, despite reasonable efforts on the part of my therapist that the transmission of my medical information could be disrupted or distorted by technical failures. In addition, I understand that telehealth-based services and care may not be as beneficial as face[1]to-face services. I also understand that if my therapist believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a counselor/therapist who can provide such services in my geographic area. 3. I understand that I may benefit from telehealth but that results cannot be guaranteed or assured. 4. I understand that I have a right to access my mental health information and copies of medical records in accordance with Washington state law. I have read and understand the information provided above. As part of this, I’ve had the opportunity to bring up any questions or concerns I have regarding this consent form and I’ve had them addressed to my satisfaction. My signature below indicates my informed consent to telehealth treatment as outlined above with ExpectGreaThings Counseling.
___________________________________________________________________________ Client’s Name (Printed) & Signature / Date ___________________________________________________________________________ Provider’s Name & Signature/ Date