Introduction of Telebehavioral Health & Financial Policies:
As a client or patient receiving behavioral services technologies, I understand:
1. Telehealth is the delivery of behavioral health services using interactive technologies
(use of audio, video or other electronic communications) between a practitioner and a
client/patient who are not in the same physical location.
2. The interactive technologies used in telebehavioral health incorporate network and software
security protocols to protect the confidentiality of client/patient information transmitted via any
electronic channel. These protocols include measures to safeguard the data and to aid in
protecting against intentional or unintentional corruption
3. Software Security Protocols: Electronic systems used will incorporate network and software
security protocols to protect the privacy and security of health information and imaging data
and will include measures to safeguard the data to ensure its integrity against intentional or
unintentional corruption. I use a HIPPA approved platform for sessions however text and telephone conversations are not HIPPA compliant. You will receive an invitation with a
way to contact me for the session.
Benefits & Limitations:
4. This service is provided by technology (including but not limited to video, phone, text, apps and
email) and may not involve direct face to face communication. There are benefits and
limitations to this service.
Technology Requirements:
You will need access to, and familiarity with, the appropriate technology in order to participate
in the service provided. Most people can use their computer, tablet or smart phone.
Exchange of Information:
5. The exchange of information will not be direct, and any paperwork exchanged will likely be
provided through electronic means or through postal delivery. You will be asked to fill out
paperwork from my website before the first session.
6. During the telehealth consultation, details of your medical history and personal
health information may be discussed.
7. You have the option to withhold consent at this time or to withdraw this consent at any time,
including any time during a session, without affecting the right to future care, treatment, However at this time tell the hell is all this provider can offer.
8. The potential benefit of Telemental health services is that you will be able to talk with the
therapist today from your computer or phone or device and receive therapy.
9. The potential risk of Telemental health services is that there could be a partial or complete
failure of the equipment being used which could result in the therapist’s inability to complete
the session.
10. There is no permanent video or voice recording kept of the Telemental health service’s session.
11. All existing laws regarding client access to mental health information and copies of mental
health records apply. All existing confidentiality protections apply.
12. Modification Plan: We will regularly reassess the appropriateness of continuing to deliver
services through the use of the technologies we have agreed upon today, and modify our plan as needed.
13. Client Communication: It is your responsibility to maintain privacy on the client end of
communication.
14. Insurance companies, those authorized by the client, and those permitted by law may also have
access to records or communications.
15. Emergency Care: I acknowledge, however, that if I am facing or if I think I may be facing an
emergency situation that could result in harm to me or to another person; I am not to seek a
telebehavioral consultation. Instead, I agree to seek care immediately through my own local
health care practitioner or at the nearest hospital emergency department or by calling 911
These are the names and telephone numbers of my local emergency contacts (i.e. local
physician; crisis hotline; trusted family, friend, or adviser). I have provided two emergency
contact numbers and the number to the local hospital or other facility as deemed appropriate.
If there is an emergency during a session, my therapist has permission to contact my
emergency contacts and the local law enforcement if necessary. I have provided a working
telephone number to reach me if the video conferencing connection fails during a session. My
therapist has provided me with a contact number. If connections fail and my counselor does
not call me back within 5 minutes, then I will call my therapist.
