Telehealth Consent – English rev 20210212

revised 2021-02-12


    Telehealth allows CFA clinicians/practitioners to diagnose/evaluate, consult, treat, educate, and manage my care using interactive audio, video or data communication. I hereby consent to participating in psychotherapy, psychiatric evaluation and medication management via telephone or the internet (hereinafter referred to as Telehealth) with my CFA providers:

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  • This form is an addendum to the Client Rights and Responsibilities form signed at the time of intake and those rights and responsibilities remain in place.

    I understand I have the following rights under this agreement:

    1. I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy and evaluation/medication management appointments. Any information disclosed by me during the course of my treatment, therefore, is generally confidential.
    2. There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my therapist has the right to break confidentiality to prevent the threatened danger. Further, I understand that sharing of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my written consent. I agree not to record and/or distribute my telehealth therapy sessions.
    3. I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our telehealth appointments could be disrupted or distorted by technical failures or could be interrupted.
    4. You or your CFA provider(s) may determine that a higher level of care than Telehealth is required to meet your unique treatment needs, at which time a referral will be made to the appropriate provider.
    5. Refusal to participate in telehealth if no other type of service is available due to office closure, will result in referral to a higher level of care.

    I have read and understand the information provided above. I have the right to discuss any of this information with my clinician and to have any questions I may have regarding my treatment answered to my satisfaction.

    I understand that I can withdraw my consent to Telehealth communications at any time verbally and in writing.

    My signature below indicates that I have read this Agreement, agree to its terms, and consent to participate in services.

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