Telebehavioral Health Informed Consent Introduction of Telebehavioral Health:

As a client or patient receiving behavioral services through telebehavioral health technologies, I understand:

Telebehavioral health 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.

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.

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.

Benefits & Limitations:

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:

I will need access to, and familiarity with, the appropriate technology in order to participate in the service provided.

Exchange of Information:

The exchange of information will not be direct and any paperwork exchanged will likely be provided through electronic means or through postal delivery.

During my telebehavioral health consultation, details of my medical history and personal health information may be discussed with myself or other behavioral health care professionals through the use of interactive video, audio or other telecommunications technology.

Local Practitioners: If a need for direct, in-person services arises, it is my responsibility to contact my behavioral practitioner’s office for an in-person appointment or my primary care physician if my behavioral practitioner is unavailable. I understand that an opening may not be immediately available in either office.

Self-Termination:

I may decline any telebehavioral health services at any time without jeopardizing my access to future care, services, and benefits.

Risks of Technology:

These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. Modification Plan:

My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies we have agreed upon today, and modify our plan as needed.

Emergency Protocol:

In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means: In emergency situations

▪ Call 911 or go to nearest emergency room

Disruption of Service:

Should service be disrupted

▪ ___Therapist will attempt to reconnect via phone or text, and if necessary email

Practitioner Communication:

My practitioner may utilize alternative means of communication in the following circumstances:

o __If typical tele-services are not operating

My practitioner will respond to communications and routine messages within __2 business days________

Client Communication:

It is my responsibility to maintain privacy on the client end of communication. Insurance companies, those authorized by the client, and those permitted by law may also have access to records or communications. I will take the following precautions to ensure that my communications are directed only to my psychologist or other designated individuals:

o finding a confidential space to have sessions_

o utilizing SimplePractice tele-services which are HIPPA-compliant when possible__

My communication exchanged with my practitioner will be stored in the following manner:

o my client file notes via SimplePractice

Laws & Standards:

The laws and professional standards that apply to in-person behavioral services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.