Tele-mental Health Consent Form Telemental health refers to psychotherapy services that occur via phone, email, or synchronous video conferencing. All our interactions will occur using synchronous video. When using technology there is always the risk of security issues, as well as technical issues (phone not charged, computer or software not working, etc.). You will be sent a link through e-mail that allows you to meet me online.In addition to the identified risks, there are several benefits that come from using technology. For instance, 1) It allows therapists to connect with people who may otherwise not be able to access services; 2) There is an opportunity for more flexibility in scheduling; 3) You have the convenience of being able to connect from a space of your choosing. To protect your confidentiality and to facilitate the security of your information as much as possible, here is a list of recommendations:1. Engage in sessions in a private location where you cannot be heard by others. 2. Please dress appropriately as you would for any in-person session. 3. Use a private phone. 4. Do not record any sessions. 5. Password protect any technology you will be interacting with your therapist on. 6. Always log out or hang up once sessions are complete.Emergency Management PlanIn the event of an emergency, it is imperative you are aware of resources in your area. As a precaution, please identify two (2) nearby emergency hospitals below. In addition, you will need to provide information for an emergency contact person. These all need to be filled out to participate in telemental health services. The Crisis Clinic is always available for emergency needs. Their number is 206-461-3222 as an alternative you may dial 911.Hospital #1 Name* Hospital #1 Phone*Hospital #1 AddressHospital #2 Name Hospital #2 PhoneHospital #2 AddressEmergency Contact Name* Emergency Contact Number*Driver’s License or IDMax. file size: 128 MB.Insurance Card front and backMax. file size: 128 MB.Contacting Your TherapistEmail is the main form of contact that will be used outside of our sessions. Please note that email is not secure, so communication should be limited to scheduling questions, providing resources, and supplying any applicable insurance information.Payment for Services Payments for services are only accepted via credit card. Payment is due at the time of service. Please check with your Insurance to ensure that you have coverage for telehealth visits, what your co-pay is and what deductibles are due before they begin payment. For your convenience you may fill out the credit card information and fax it to me before we meet at 206-243-9583 or provide it at the time of service if I do not have a current card on file.Name on Card Credit Card Number Expiration Month(MM) Expiration Year(YY) Number3 Digit Code (From Back of Card)Billing Zip Code Emergency Contact Name* Phone*Relationship to Patient* Appointment Changes/Cancellation If you need to cancel or change an appointment, please do so as early as possible. Cancellations made with less than a 24-hour notice of your appointment time will be charged $110.00. All co-pays and session fees are due at the time service.Authorization for Treatment I,Name* authorize telehealth evaluation and treatment fromSound Christian Counseling, Inc. I acknowledge that I may request a copy of this informed consent agreement. It is agreed that either of us may discontinue treatment at any time by verbal or written notice at least 24 hours prior to a scheduled appointment.Signature*Date* MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
