TELEHEALTH SERVICES INFORMATION
What are Telehealth services and when are they used?
Telehealth services are used when mental health practitioners cannot be physically present with you to evaluate your mental health needs (or provide supervision consultation) face-to face. A mental health clinician may be present at another location and available to serve you through newly available technology. Instead of talking to someone on the phone at another location, telehealth services use a video camera and computer to send both voice and personal images (pictures) between you and a mental practitioner so not only can you talk to each other, but you can also see each other. This allows mental health staff to make a better evaluation of your needs.
How do Telehealth services/consultations work?
You will be in the privacy of your own location with a computer with a video camera. The mental health practitioner will also be in a private room but at another location with the same type of equipment. When the session is ready to begin, your clinician will start the computer and camera so that you and your therapist can see each other and talk together. When the session is over, your clinician will shut off the equipment.
How is it different than a regular session with my provider?
Other than not being in a room together, there is very little difference in the session. Your therapist will ask and document clinical information that you share, document the service that is provided, and ensure that documentation is included in your clinical record for future reference.
What happens if I choose not to consent to Telehealth services?
If you choose not to consent to Telehealth services, we will explore how to arrange for services to be rescheduled for a later time or discuss referring you to an alternate provider.
CONSENT FOR DISTANCE CONSULTATIONS OR TELEHEALTH SERVICES
I understand that:
1. I have the option to withhold consent at this time or to withdraw this consent at anytime, including any time during a session, without affecting the right to future care, treatment, or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
2. The potential benefit of Telehealth services is that I will be able to talk with mental health practitioner today from this local setting for an evaluation of my needs. When appropriate, I will also be able to continue my participation in mental health services uninterrupted.
3. The potential risk of Telehealth services is that there could be a partial or complete failure or compromise of the equipment being used which could result in a breach of privacy/confidentiality or the practitioner’s inability to complete the evaluation or mental health service.
4. There is no permanent video or voice recording kept of the Telehealth service’s session.
5. All existing confidentiality protections apply.
6. All existing laws regarding client access to mental health information and copies of mental health records apply.
7. Dissemination of client identifiable images or information from the Telehealth interaction to researchers or other entities shall not occur without the consent from the client.
I, ________________________________, consent to Telehealth services in circumstances in which my appropriate mental health needs may not be (immediately) met due to unavailability for regular face-to-face sessions; or if I prefer/choose to receive services in this manner. My mental health care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information, and all of my questions have been answered. I understand the written information provided above.
Signature of Client* Date
Signature of Responsible Adult** Date
Relationship to Client