I, the client, need to be a resident of Hawaii or a state where my provider is licenced in.
I, the client, have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
The laws that protect the confidentiality of my medical information also apply to telemedicine and teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are described in the general Consent Form I received at the start of my treatment with my provider under the law.
I understand that there are risks and consequences of participating in telemedicine or teletherapy, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my psychologist, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
There is a risk that services could be disrupted or distorted by unforeseen technical problems.
In addition, I understand that telehealth-based services and care may not be as complete as face-to-face services. I also understand that if my practitioner believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I may be referred to a professional who can provide such services in my area or asked to attend an in person session if available.
I understand that I may benefit from telehealth, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form of care and treatment, and that despite my efforts and the efforts of my practitioner, my condition may not improve, and in some cases may even get worse
I accept that telehealth does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support.
Clients who are actively at risk of harm to self or others are not suitable for telehealth services. If this is the case or becomes the case in future, my practitioner will recommend more appropriate services.
I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in teletherapy. I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my telehealth sessions, and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session. It is the responsibility of the treatment provider to do the same on their end.
I understand that dissemination of any personally identifiable images of information for the telemedicine interaction to researchers or other entities shall not occur without my and my providers written consent.
I understand that video and audio sessions through telehealth platforms may be recorded for the safety of myself and the practitioner
I understand that miscommunication between myself and my therapist may occur via Telehealth.