Telehealth treatment consent

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 Doxy.me and VSee are HIPAA compliant video web and video conferencing platforms. I understand that Doxy.me and VSee encryption fully complies with HIPAA security standards that ensures the security and privacy of all client data. *

I Understand

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. *

I Understand

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. *

I Understand

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. *

I Agree

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. *

I Understand

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. *

I Understand

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. *

I Agree

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. *

I Understand

* Indicates required field

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.Name *

First

Last

Submit

​Informed Consent for Video/phone Therapy Sessions

Informed Consent for Video/phone Therapy Sessions