I hereby consent to participate in Telemental Health with my therapist at the Office of Travis Atkinson, LCSW, PC and Loving at Your Best Marriage and Couples Counseling, PC as part of my psychotherapy.
I understand that Telemental Health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.
I understand the following with respect to Telemental Health:
1). I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled. If it is not possible or my therapist determines that I am not best served through a Telemental Health option to meet online using Telemental Health, Travis Atkinson, LCSW, LICSW will assist me in finding a new therapist.
2). There are risks, benefits, and consequences associated with Telemental Health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
3). There will be no recording of any of the online sessions by either party, unless otherwise agreed by myself and Travis Atkinson, LCSW, LICSW. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
4). The privacy laws that protect the confidentiality of my protected health information(PHI) also apply to Telemental Health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
5). If I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care may be required which may include referrals to more appropriate resources.
6). During a Telemental Health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call us at 646-699-4149 to re-schedule.
7). My therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency that I will provide before my session begins and also include in my Counsol.com contact information portal.
As required by state laws, your therapist needs to know your location in case of an emergency when a session takes place.
I agree to inform my therapist of the address where I am physically located at the beginning of each session.
I agree to provide my therapist with en emergency contact person’s name and mobile number who they may contact on my behalf in a life-threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.
In case of an emergency, I agree to include my emergency contact person’s name, address, and cell number phone within your intake form. If this information changes, I agree to update the intake form on the Counsol.com portal immediately, and will notify my therapist of the change.