Telemental Health Informed Consent
I hereby consent to to allow my child. participate in Telehealth services with Every
Mind, as part of my psychotherapy. I understand that Telehealth 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 Telehealth health:
1. I understand that 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.
2. I understand that there are risk and consequences associated with Telehealth 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. I understand that there will be no recording of any of the online sessions by either
party. 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. I understand that the privacy laws that protect the confidentiality of my protected
health information (PHI) also apply to Telehealth 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. I understand that 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 Telehealth health services are not appropriate and a
higher level of care is required.
6. I understand that during a Telehealth 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 me at the number indicated on this form to
discuss since we may have to re-schedule.
7. I understand that my therapist may need to contact my emergency contact and/or appropriate
authorities in case of an emergency.
Emergency Protocols
I need to know your location in case of an emergency. You agree to inform me of the address
where you are at the beginning of each session. I also need a contact person who I may contact
on your 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.