Telehealth Consent Section

INFORMATION ABOUT TELEHEALTH

What are Telemental health services and when are they used?

Telemental health services are used when mental health staff cannot be physically present with you to evaluate your mental health needs. Mental health staff may be present at another location and available to serve you through audio/visual technology. Telemental health services use a video camera and computer to send both voice and personal images (pictures) between you and mental health staff 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 Telemental health services work?

You will be in a private room by yourself with necessary computer and video camera equipment. The mental health staff will also be in a private room but at another location with the same type of equipment. When the session is ready to begin, a counselor will start the computer and camera so that you and he/she can see each other and talk together. When the session is over, the counselor will end the meeting..

How is it different than a regular session with mental health staff?

Other than you and your counselor not being in a room together, there is very little difference in the session. The counselor will ask and document clinical information that you share with him/her, document the service that is provided, and ensure that documentation is included in your clinical record for future reference.

What will I need to receive Telemental Health services?

You will need to download the Zoom application at zoom.us to use this platform. Zoom is available on all devices: PC, Mac, IOS and Android. You also need to have a broadband Internet connection or a smart phone access with a good cellular connection at home or at the location deemed appropriately confidential for services. In the event of technology failure, you will need to utilize phone services to inform your student counselor of the technology failure. If the video meeting cannot be held, you and your counselor may opt to connect via your phone connection.

What happens if I choose not to consent to Telemental health services?

If you are a client of Dr. Sparrow, and you choose not to consent to Telemental health services, Dr. Sparrow may be able to see you in his office. However, his associates only see their clients online, so you will not be able to see one of our Associates if you decline to receive Telehealth services.

CONSENT FOR TELEMENTAL HEALTH SERVICES

I hereby consent to engaging in telehealth counseling via Zoom as part of my counseling services. I understand that “telehealth” allows my counselor to diagnose, consult, treat and educate using interactive audio, video or data communication regarding my treatment.

Technology: I understand I will need the Zoom application at zoom.us to use this platform, a broadband Internet connection or a smart phone device with a good cellular connection, and a remote location appropriate for services. Also, in the event of technology failure, I am responsible for contacting my counselor via phone to inform them of the technology failure.

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. I understand that my counselor guarantees confidentiality at his/her location and I am responsible to find a remote location that is reasonably free of distractions and interruption for my sessions. Any information disclosed by me during my therapy, 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 counselor may be required to break confidentiality to prevent the threatened danger and immediately notify their faculty supervisor.

3. There is no permanent video or voice recording kept of the Telemental health service’s session (unless temporarily saved if you approve of videotaping for supervision purposes -- see above). I understand that the dissemination of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my prior written consent.

4. I further understand that there are risks unique to Telehealth, including but not limited to, the possibility that sessions or other communication by my student counselor to others regarding my treatment could be disrupted or distorted by technical failures, or could be interrupted, or could be accessed by unauthorized persons.

5. I have the option to withhold consent or to withdraw this consent at any time.

I have the right to discuss any of this information with my counselor or Dr. Sparrow (if different) in order to have any questions regarding my treatment answered to my satisfaction. My signature indicates that I have read and understood this information and agree to its terms.