Accepted Therapy

Information and Informed Consent for Telehealth Treatment

Telehealth is live two-way audio and/or video electronic communications that allows therapists and clients to meet outside of a physical office setting.

Client Understanding

I understand that telehealth services are completely voluntary and that I can withdraw this consent at any time.

I understand that none of the telehealth sessions will be recorded or photographed.

I agree not to make or allow audio or video recordings of any portion of the sessions.

I understand that the laws that protect privacy and the confidentiality of client information also apply to telehealth, and that no information obtained in the use of telehealth that identifies me will be disclosed to other entities without my consent.

I understand that telehealth is performed over a secure communication system that is almost impossible for anyone else to access. I understand that any internet-based communication is not 100 % guaranteed to be secure.

I agree that my therapist and Accepted Therapy Services will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.

I understand that I or my therapist may discontinue the telehealth sessions at any time if it is felt that the video technology is not adequate for the situation.

I understand that if there is an emergency during a telehealth session, then my therapist may call emergency services and/or my emergency contact.

I understand that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and that all office policies and procedures apply to telehealth services.

I understand that if the video conferencing connection drops while I am in a session, I will have an additional phone line available to contact my therapist, or I will make additional plans with my therapist ahead of time for recontact. My therapist may choose to use a different means of technology (Zoom, FaceTime, Google Meets) for completion of my session; however, these other means may not be HIPPA compliant.

I understand my therapist will advise me about what telehealth platform to use and she will establish a video conference session. I also recognize that if I am more than 10 minutes late to a telehealth session, I will be charged the standard no-show fee.

I understand a “no show” or late fee of $75.00 will be charged if I miss an appointment or do not cancel within 24 hours of scheduled appointment. I understand credit card or other form of payment will be established before the first session and that insurance is not responsible for any late or no-show fees accrued.

B. Therapy Tools

Core Beliefs
Diary Card
Thought Record
Timeline

C. Book Recommendations

The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk
Atlas of the Heart: Mapping Meaningful Connection and the Language of Healing Experience by Brené Brown
Complex PTSD: From Surviving to Thriving: A Guide and Map for Recovering from Childhood Trauma by Pete Walker
Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy by Francine Shapiro
The Grief Recovery Handbook by John James and Russell Friedman

Client Consent

I here by give my informed consent for the use of telehealth in my care.

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