Tele-therapy informed consent

David Friedler, LMHC, LLC

Telehealth Informed Consent

I hereby consent to participate in telemental health with David Friedler, LMHC, LPCC, MPH as part of my psychotherapy. I understand that telehealth is the practice of delivering clinical health care services via technology-assisted media or other electronic means between a practitioner and a client located in two locations.

I understand the following with respect to telehealth:

1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

2) I understand that there are risks, benefits, and consequences associated with telemental health, including but not limited to disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization except where the disclosure is permitted and/or required by law.

4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies  (i.e., mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).

5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate, and a higher level of care is required.

6) I understand that we could encounter technical difficulties during a telemental health session, resulting in service interruptions. If this occurs, end and restart the session. If we are unable to

reconnect within ten minutes. Please call me at 617-515-4418 to discuss since we may have to reschedule.

7) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

I have read the information provided above and discussed it with my therapist. I understand the information above, and my questions have been answered satisfactorily. Mr. Friedler will send you a form by secure email. By clicking the button on the submission form, I indicate that I know the above and agree to use telehealth services in lieu of or in addition to in-person visits. 

Mr. Friedler will send you a copy of this form for your signature.