Informed Consent for Video/phone Therapy Sessions
1. I understand that I am about to engage in a video or phone therapy session with Kurt Hadrika M.S., L.M.H.C., L.M.F.T. I am aware that Zoom is a HIPAA compliant video web and video conferencing platform. I understand that Zoom’s encryption fully complies with HIPAA security standards that ensures the security and privacy of all client data.
2. I understand that the video conferencing technology or phone will not be the same as an in-person session with a provider due to the fact that I will not be in the same room as my provider. I also understand that, in order to have the best results for this session, I should be in a quiet place with limited interruptions when I start the session.
3. I understand the potential risks to this technology, include interruptions, and technical difficulties. I understand that my provider or I can discontinue the video therapy session or phone call if it is felt that the videoconferencing or phone connections are not adequate for the situation.
4. My provider agrees to inform me and obtain my consent if another person is present during the consultation, for any reason. I agree to inform my provider if there is another person present during the session.
5. I understand that this consent will last for the duration of the relationship with my provider, including any additional video therapy or phone sessions I may have. I can withdraw my consent for a video therapy or phone sessions at any time.
6. I understand that the same confidentiality protections, limits to confidentiality, and rules around my records apply to video therapy and phone sessions as they would in an in-person session.
7. I agree to work with my provider to come up with a safety plan, including identifying one or two emergency contacts, in the event of a crisis situation during our sessions.
8. I understand that my provider may decide to terminate video therapy or phone sessions, if he deems it inappropriate for me to continue therapy through telehealth.
By signing this form, I certify:
● That I have read or had this form read and/or had this form explained to me.
● That I fully understand its contents including the risks and benefits of the procedure(s).
● That I have been given opportunity to ask questions and that any questions have been answered to my satisfaction.
● That I agree to participation in a video or phone session(s) with Kurt Hadrika M.S., L.M.H.C., L.M.F.T.
1. I understand that I am about to engage in a video or phone therapy session with Kurt Hadrika M.S., L.M.H.C., L.M.F.T. I am aware that Zoom is a HIPAA compliant video web and video conferencing platform. I understand that Zoom’s encryption fully complies with HIPAA security standards that ensures the security and privacy of all client data.
2. I understand that the video conferencing technology or phone will not be the same as an in-person session with a provider due to the fact that I will not be in the same room as my provider. I also understand that, in order to have the best results for this session, I should be in a quiet place with limited interruptions when I start the session.
3. I understand the potential risks to this technology, include interruptions, and technical difficulties. I understand that my provider or I can discontinue the video therapy session or phone call if it is felt that the videoconferencing or phone connections are not adequate for the situation.
4. My provider agrees to inform me and obtain my consent if another person is present during the consultation, for any reason. I agree to inform my provider if there is another person present during the session.
5. I understand that this consent will last for the duration of the relationship with my provider, including any additional video therapy or phone sessions I may have. I can withdraw my consent for a video therapy or phone sessions at any time.
6. I understand that the same confidentiality protections, limits to confidentiality, and rules around my records apply to video therapy and phone sessions as they would in an in-person session.
7. I agree to work with my provider to come up with a safety plan, including identifying one or two emergency contacts, in the event of a crisis situation during our sessions.
8. I understand that my provider may decide to terminate video therapy or phone sessions, if he deems it inappropriate for me to continue therapy through telehealth.
By signing this form, I certify:
● That I have read or had this form read and/or had this form explained to me.
● That I fully understand its contents including the risks and benefits of the procedure(s).
● That I have been given opportunity to ask questions and that any questions have been answered to my satisfaction.
● That I agree to participation in a video or phone session(s) with Kurt Hadrika M.S., L.M.H.C., L.M.F.T.