Telehealth Consent Form
Telehealth Consent Form—Digital Copy
INFORMATION, AUTHORIZATION, & CONSENT TO TELEMENTAL HEALTH TREATMENT
This document is designed to inform you about what you can expect from your counselor regarding confidentiality, emergencies, and several other details regarding your treatment as it pertains to the use of TeleMental / TeleBehavioral Health. Please bear with me as this form is long due to the extensive requirements of the State Board of Examiners. Additionally, please note that I am only able to conduct TeleMental / TeleBehavioral Health sessions in the State of Texas.
TeleMental / TeleBehavioral Health is defined as follows:
“TeleMental / TeleBehavioral Health means the mode of delivering services via technology assisted media, such as but not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system or other electronic means using appropriate encryption technology for electronic health information.”
TeleMental / TeleBehavioral Health is a relatively new concept even though many therapists have been using technology-assisted media for years. Breaches of confidentiality over the past decade have made it evident that Personal Health Information (PHI) as it relates to technology needs an extra level of protection. Additionally, there are several other factors that need to be considered regarding the delivery of TeleMental / TeleBehavioral Health services in order to provide you with the highest level of care.
Therefore, I have completed specialized training in TeleMental / TeleBehavioral Health training to follow board rules. I have also developed several policies and protective measures to assure you PHI remains confidential. These are discussed below.
The Different Forms of Technology-Assisted Media Explained
Telephone via Landline
It is important for you to know that even landline telephones may not be completely secure and confidential. There is a possibility that someone could overhear or even intercept your conversations with special technology. Individuals who have access to your telephone or your telephone bill may be able to determine who you have talked to, who initiated that call, and how long the conversation lasted. If you have a landline and you provided me with that phone number, I may contact you on this line from my own landline in my office or from my cell phone, typically only regarding setting up an appointment if needed. If this is not an acceptable way to contact you, please let me know. Telephone conversations (other than just setting up appointments) are billed at my hourly rate.
Cell Phones
In addition to landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone could overhear or intercept your conversations. Be aware that individuals who have access to your phone or your cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call occurred. However, I realize that most people have and utilize a cell phone. I may also use a cell phone to contact you, typically only regarding setting up an appointment if needed. Telephone conversations (other than just setting up appointments) are billed at my hourly rate.
If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24 business hours. Please note that face-to-face sessions are highly preferable to Telehealth sessions and may be required PRIOR to a Telehealth. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or go to any local emergency room
Email is generally not a secure means of communication and may compromise your confidentiality. Nonetheless, please know that it is my policy to utilize Hushmail and Gsuite which are both HIPAA compliant secure platforms, as means of communication strictly for appointment confirmations, sending referrals or resources, and sending necessary consent forms and other paperwork. Please do not bring up any therapeutic content via email to prevent compromising your confidentiality. You also need to know that I am required to keep a copy or summary of all emails as part of your clinical record that address anything related to therapy. I strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g. has a firewall, anti-virus software installed, is password-protected, not accessing the Internet through a public wireless network, etc.) If you are in a crisis, please do not communicate this to me via email because I may not see it in a timely matter. Instead, please see below under “Emergency Procedures.”
Social Media-Facebook, Twitter, LinkedIn, Instagram, Pinterest, Etc.
It is my policy not to accept “friend” or “connection” requests from any current or former client on my personal social networking sites such as Facebook, Twitter, Instagram, Pinterest, LinkedIn etc. because it may compromise your confidentiality and blur the boundaries of our relationship. However, I have social media pages as a professional. You are welcome to “follow” me on this professional page where I post counseling information. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to Morgan Doolittle. Please refrain from making contact with me using social media messaging systems such as Facebook Messenger. These methods have insufficient security, and I do not watch them closely. I would not want to miss an important message from you.
Telehealth by Simple Practice Service:
I/we agree to use the video-conferencing platform selected (SimplePractice) for our virtual sessions, and my therapist will explain how to use it. Telehealth by SimplePractice is the technology service Morgan Doolittle PLLC will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
- Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911 or proceed to the nearest emergency facility as identified in my tele-health safety plan.
- Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
- The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice, or care.
- I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate, or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
- To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
- SimplePractice always transmits account information securely with multiple layers of encryption. Your passwords are encrypted and not accessible to anyone but you. Servers are housed in a secure facility protected by proximity readers, biometric scanners, and security guards 24 hours a day, 7 days a week, 365 days a year. [SimplePractice]: We hack our own site. SimplePractice runs thousands of tests on its own software to ensure security. We scan our ports, test for SQL injection, and protect against cross-site scripting. Bank-level security. SimplePractice has received the VeriSign security seal.
- Statement from SimplePractice concerning security: Web pages and APIs are secured with 128-bit Secure Socket Layer encryption. Our cloud infrastructure uses multi-factor authentication. We use advanced key management and transparent data encryption. Features include the following: Application-level monitoring and intrusion protection. HIPAA compliant encryption. HIPAA compliant hosting architecture on enterprise-level hardware. HIPAA compliant system architecture with separate web and database environments. Application and Database server isolation. Firewall management. Log retention with a detailed audit trail. Managed and secured backup and disaster recovery. Managed patching, version control, and security updates. Credit card transactions processed using secure encryption on a PCI compliant network.
Telehealth by Zoom Platform Service:
Video Conferencing is an option for us to conduct remote sessions over the internet where we not only can speak to one another, but we may also see each other on a screen. I utilize the platform Zoom, as a backup platform to Simple Practice, an encrypted platform that is not HIPAA compliant at this time. In order to add security and encryption to our video conferencing, there will be an additional password to sign in that will be specific to your session. If we choose to utilize this technology, you can start an appointment directly from your web browser on your computer or tablet or mobile phone using Firefox or Google Chrome. You will receive an email reminder that includes a link to join the video call. I also ask that you sign on to the platform at least five minutes prior to your session time to ensure we get started promptly.
Payment:
I understand that in order to receive services at Morgan Doolittle, PLLC, I must agree to keep a method of payment such as a credit, debit, or HSA card on file, stored through the SimplePractice portal, which will be visible to you as the client and not your provider.
Your Responsibilities for Confidentiality & TeleMental / TeleBehavioral Health:
Please communicate only through devices that you know are secure as described above. It is also your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, strangers, and hackers could either overhear your communications or have access to the technology that you are interacting with. Additionally, you agree not to record any TeleMental / TeleBehavioral Health sessions.
I currently do not accept insurance but am happy to work with you on a sliding scale to help meet your needs.
Communication Response Time:
I am required to make sure that you’re aware that I’m located in Texas and therefore abide by the Central Time Zone. Morgan Doolittle PLLC is an outpatient facility, and is set up to accommodate individuals who are reasonably safe and resourceful. I am not on call 24 hours and am not available at all times. If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a therapist or clinic with 48-hour availability. I will return phone calls within 48 hours. However, I do not return calls or emails on weekends or holidays. If you are having a mental health emergency and need immediate assistance, please follow the instructions below.
Emergency Procedures Specific to TeleMental / TeleBehavioral Health Services:
If you are in crisis, please call the 24-hour crisis hotline @ 1-800-758-2423, Text 741741 from anywhere in the USA to text with a trained Crisis Counselor, call 911 or go to your nearest hospital.
There are additional procedures that we need to have in place specific to TeleMental / TeleBehavioral Health services. These are for your safety in case of an emergency and are as follow:
• You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and TeleMental / TeleBehavioral Health services are not appropriate.
• I require an Emergency Contact Person (ECP) who I may contact on your behalf in a life-threatening emergency only. Please provide this person’s name and contact information where indicated on this form. Your signature at the end of this document indicates that you understand I will only contact this individual in the extreme circumstances stated above.
• You agree to inform me of the address where you are at the beginning of every TeleMental /TeleBehavioral Health session.
• You agree to inform me of the nearest mental health hospital to your primary location that you prefer to go to in the event of a mental health emergency
Limitations of TeleMental / TeleBehavioral Health Therapy Services:
TeleMental / TeleBehavioral Health services should not be viewed as a complete substitute for therapy conducted in my office unless there are extreme circumstances that prevent you from attending therapy in person. It is an alternative form of therapy or adjunct therapy, and it involves limitations. Primarily, there is a risk of misunderstanding one another when communication lacks visual or auditory cues. For example, if the video quality is lacking for some reason, I might not see a tear in your eye. Or, if audio quality is lacking, I might not hear the crack in your voice that I could easily pick up if you were in my office. There may also be a disruption to the service (e.g. phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of personal interaction.
In Case of Technology Failure:
During a TeleMental / TeleBehavioral Health session, we could encounter a technological failure. The most reliable backup plan is to contact one another via telephone. Please make sure you have a phone with you, and I have that phone number. If we get disconnected from a video conferencing or chat session, end the session on your electronic device and restart the session. If we are unable to reconnect within ten minutes, please call me. If we are on a phone session and we get disconnected, please call me back or contact me to schedule another session. If the issue is due to my phone service, and we are not able to reconnect, I will not charge you for that session.
Structure and Cost of Sessions:
I may provide phone, and/or video conferencing if your treatment needs determine that TeleMental / TeleBehavioral Health services are appropriate for you. If appropriate, you may engage in either face-to-face sessions, TeleMental / TeleBehavioral Health, or both. We will discuss what is best for you. The structure and cost of TeleMental / TeleBehavioral Health sessions are the same as face-to-face sessions described in my New Client Intake form. I require a credit card ahead of time for TeleMental / TeleBehavioral Health therapy for ease of billing. Your credit card will be charged at the conclusion of each TeleMental / TeleBehavioral Health interaction. This includes any therapeutic interaction other that setting up appointments. You are responsible for the cost of any technology you may use at your own location. This includes your computer, cell phone, tablet, internet or phone charges, software, headset, etc.
In the event that you are unable to keep either a face-to-face appointment or a TeleMental / TeleBehavioral Health appointment, you must notify me at least 24 hours in advance. If such advance notice is not received, you will be financially responsible for the session you missed.
Consent to TeleMental / TeleBehavioral Health Services:
Together, we will ultimately determine which modes of communication are best for you. However, you may withdraw your authorization to use any of these services at any time during the course of your treatment just by notifying me in writing. If you do not see an item discussed previously in this document listed for your authorization below, this is because it is built-in to my practice, and I will be utilizing that technology unless otherwise negotiated by you. In summary, technology is constantly changing, and there are implications to all the above that we may not realize at this time. Feel free to ask questions, and please know that I am open to any feelings or thoughts you have about these and other modalities of communication and treatment.
Please sign your name below indicating that you have read and understood the contents of this form, you agree to these policies, and you are authorizing me to utilize the TeleMental / TeleBehavioral Health methods discussed.