New Client: Telemental Health Consent

TELEMENTAL HEATH INFORMED CONSENT

Telemental Health is the delivery of psychotherapeutic services using interactive audio and visual electronic systems and/or by the electronic transmission of information where the provider and the client are not in the same physical location. 

 The interactive electronic systems incorporate network and software security protocols to protect patient information and safeguard the data exchanged. 

 Potential benefits 

1. A computer and a webcam can provide live video conferencing using software that can be free to patients. 
2. Telemental health provides convenience and increased accessibility to mental health care for patients who are unable to be treated face to face due to various reasons such as living in remote locations, temporary circumstances such as being away at college, an extended stay away from home, or having a physical limitation preventing travel to our office. 

 

Potential Risks  

As with any mental health procedure, there may be potential risks associated with the use of telemental health. These risks include, but may not be limited to:  

1. Information transmitted electronically may not be sufficient (e.g., poor resolution of video) to allow for appropriate decision making by the psychiatrist or therapist.  
2. The provider is not able to provide every type of mental health treatment using interactive electronic equipment.  
3. The provider may not be able to provide for or arrange for emergency care that I may require, in cases of connection failure.  
4. Delays in mental health evaluation and treatment may occur due to deficiencies or failures of the equipment.  
5. Although unlikely, security protocols can fail, causing a breach of privacy of my confidential medical information.  
6. A lack of access to all the information that might be available in a face-to-face visit but not in a telemental health session may result in errors in clinical judgment.  

 

Alternatives to the use of telemental health 

• Face-to-face session in the mental health provider’s office.  

• Referral to another mental health provider.  

  

My Rights 

• I understand that the laws that protect the privacy and confidentiality of medical information also apply to telemental health. 

• I understand that the videoconferencing technology used by the provider is encrypted to prevent unauthorized access to my private medical information.  

• I have the right to withhold or withdraw my consent to the use of telemental health during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.  

• I understand that the provider has the right to withhold or withdraw his or her consent for the use of telemental health during the course of my care at any time.  

• I understand that the provider will not record any of our telemental health sessions without my written consent.  

• I understand that the provider will not allow any other individual to listen to, view or record my telemental health session without my written permission.  

 

My Responsibilities  

• I will not record any telemental health sessions without written consent from the provider. I will inform the provider if any other person can hear or see any part of our session before the session begins. The provider will not allow any other person to hear or see any part of our session.  

• I understand that I, not the provider, am responsible for providing and configuring any electronic equipment used on my computer that is used for telemental health. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins.  

• I understand that I must provide emergency contact information for persons in my location and give consent for them to be contacted in case of medical or mental health emergencies prior to commencing telemental health treatment. 

PATIENT CONSENT FOR THE USE OF TELEMENTAL HEALTH

I have read and understand the information provided above regarding telemental health. I acknowledge that my participation in the telemental health process is voluntary and may possibly increase the risk of disclosure of my personal data. I hereby give my informed consent for the use of telemental health in my mental health care in the course of my diagnosis and treatment. 

You can digitally sign this consent form by typing the following phrase:

I agree to the terms in this consent form.

Then, type your name in the signature field.