Informed Consent for
Telehealth Services

Definition of Telehealth

Telehealth involves the use of electronic communications to enable Family Service Rochester’s mental health professionals to connect with individuals using interactive video and audio communications.

Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data. Family Service Rochester’s Telehealth Services use cameras, telephones and monitors to connect you to mental health professionals at distant locations. When you have an appointment through telehealth, you will have the opportunity of seeing, hearing, and talking to a mental health professional via a two-way monitor.

What is important here is that you are aware that tele-therapy may or may not be as effective as in-person therapy and therefore we must pay close attention to your progress and periodically evaluate the effectiveness of this form of therapy.

Because you may not have met your counselor in person, you may be requested to be interviewed by a professional in your area and allow your counselor to talk to that individual before proceeding with therapy. Your counselor will review how telehealth works and you must have the equipment on your end for services to be able to occur. This includes having a working computer/tablet/phone with the ability to download the “ZOOM” program, along with a camera, connected speakers, and internet service. If you are disconnected due to technical issues, your counselor will contact you via the phone number in your record.

I understand that I have the rights with respect to telehealth:
  1. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and expressed threats of self-harm. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.
  2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
  3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Family Service Rochester utilizes secure, encrypted audio/video transmission software to deliver telehealth.
  4. I understand that if my counselor believes I would be better served by another form of intervention (e.g.face-to-face services), I will be referred to a mental health professional associated with any form of psychotherapy, and that despite my efforts and the efforts of my counselor, my condition may not improve, and in some cases may even get worse.
  5. I understand the alternatives to counseling through telehealth as they have been explained to me, and in choosing to participate in telehealth, I am agreeing to participate using video conferencing technology. I also understand that at my request or at the direction of my counselor, I may be directed to “face-to-face” psychotherapy.
  6. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.
  7. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my counselor in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-clinical personnel to leave the telehealth room, and/or (3) terminate the consultation at any time.
  8. I understand that my express consent is required to forward my personally identifiable information to a third party.
  9. I understand that I have a right to access my medical information and copies of my medical records in accordance with the laws pertaining to the state of Minnesota.
  10. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area. If I am unable to call 9-1-1, my counselor will call to ensure my safety. I understand a crisis situation will include when I leave the area where my counselor can view and/or hear me during session and this was not agreed upon by both of us.

I have read and understand the information provided above regarding telehealth, have discussed it with my counselor, and all of my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.

Signed *:
Date *:
Name of Client or Legal Guardian *:
Phone Number *:
Email *:
Date Of Birth *:
New or Returning Client *:
If Returning - What Service?:

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