Telemental Health Consent What are Telemental health services and when are they used? Telemental health services are used when mental health staff cannot be physically present with you to provide counseling services. Mental health staff may be present at another location and available to serve you through newly available technology. Instead of talking to someone on the phone at another location, Telemental health services use a video camera and computer to send both voice and personal images (pictures) between you and mental health staff so not only can you talk to each other, but you can also see each other. This allows mental health staff to make a better assessment of your needs. How do Telemental health services work? You will need to be in a private room by yourself where you feel comfortable no one can interfere with your session. You will need a device with a video camera, speakers and microphone (ie—computer, table, cell phone). Your therapist will also be in a private room but at another location with the same type of equipment. How is it different than a regular session with mental health staff? Other than you and your therapist not being in a room together, there is very little difference in the session. You and your therapist will have a dialogue about your treatment and your therapist will document the service that is provided, and ensure that documentation is included in your clinical record for future reference. I understand that: I have the option to withhold consent at this time or to withdraw this consent at any time, including any time during a session, without affecting the right to future care, treatment, or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. The potential benefit of Telemental health services is that I will be able to talk with my therapist without coming to the office. The potential risk of Telemental health services is that there could be a partial or complete failure of the equipment being used which could result in the therapist’s inability to complete the session. In addition, security protocols could fail causing a breach of patient privacy. There is no permanent video or voice recording kept of the Telemental health service’s session. All existing confidentiality protections apply. All existing laws regarding client access to mental health information and copies of mental health records apply. Consent* I consent to Telemental health services with JP Counseling. Staff has discussed with me the information provided above. I have had an opportunity to ask questions about this information, and all of my questions have been answered. I understand the written information provided above.Name* First Last Date MM slash DD slash YYYY Signature of Client*Authentication Code* CAPTCHA
