Telehealth Consent Form
We expect to have an electronic version soon.
Until then, please download and sign the form that can be found here. Then either scan, take a photo, or fax (603-417-2172) the signed version to us.
The full text can be found below:
This consent is in addition to the regular “Therapy and Medication Management Consent, Policies and Agreement” form and “Notice of Privacy Practices” for Protected Health Information commonly known as HIPAA. You must sign all three forms in order to participate in Telehealth (video) counseling sessions. Prior to engaging in telehealth an assessment/consultation will be done to assure that video is an appropriate form of counseling for you. This is to inform you about what you can expect regarding your participation in tele-health counseling.
The benefits of telehealth are:
- The ability to expand your choice of service provider.
- More convenient counseling options including location, time, no driving, etc.
- Reduces the overall cost and time of therapy due to not having to drive to and from and office.
- Ability to have real time monitoring and reduced wait time for scheduling office appointments.
- Increased availability of services to homebound clients, those with limited mobility, and clients without convenient transportation options.
It is important to note that there are limitations to telehealth that can affect the quality of the session(s). These limitations include but are not limited to the following:
- Your therapist may not be able to observe your body language or your non-verbal reactions to what you are discussing as easily as in-person sessions.
- Due to technology limitations we may not hear all of what you are saying and may need to ask you to repeat yourself.
- Technology might fail before or during the counseling session.
- Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.
- To reduce the effect of these limitations, we may ask you to describe how you are feeling, thinking, and/or acting in more detail than we would during an in-person session.
When choosing to use video sessions, your therapist will call you at the scheduled time or send you the link for our secure and HIPAA compliant video platform, using Google Meet. We will expect that you are available at the scheduled time and are prepared, focused and engaged in the session. Your therapist will be calling you from a private location where she is the only person in the room. You also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality. If you choose to be in a place where there are people or others can hear you, your therapist cannot be responsible for protecting your confidentiality. Every effort MUST be made on your part to protect your own confidentiality. We suggest you wear earbuds to increase confidentiality and also increase sound quality of the sessions. Please ensure that you reduce all possibilities of interruptions for the duration of our scheduled appointment.
Please know that due to state laws your therapist is only able to practice in the state(s) in which they are licensed. That means wherever you reside your therapist must be licensed. You agree to inform us if your therapy location has changed or if you have relocated your domicile to a different jurisdiction.
If the connection is interrupted during a video session, your therapist will call you on the cell phone number provided on this form to troubleshoot the reason the connection was lost. Remember that the number may show up as restricted or blocked so be sure to pick it up. You may also call your therapist at 603-821-0008. If your therapist cannot reach you, she will remain available to you for 15 minutes. Should you contact your therapist and there is time left, then the session will continue. If the reason for a connection loss i.e. technology, battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session. If the loss for connection is a technology fail on the part of your therapist, you may choose to plan an alternate time to complete the remaining minutes of the session.
Recording of Sessions:
Please note that recording, screenshots, etc. of any kind of any session is not be permitted and are grounds for termination of the client-therapist relationship.
Payment for Services:
Payments for services must be made prior to each session. Your therapist will charge your card on file no more than 24 hours prior to the session.
If you must cancel or reschedule an appointment, 24-hour advanced notice is required, otherwise you will be held financially responsible. Should you cancel or miss an appointment with notification less than 24 hours this will result in being charged $100 for your missed appointment. Telehealth sessions are treated as regular in office sessions. If you are late getting on the video call, are unable to talk at our scheduled time, are unable to access a confidential place to talk, or any other variable that would have you not be able to attend our session please know that you will be charged for the session. Please make the necessary arrangements you need to be available and present for your session.
Emergencies and Confidentiality:
We require an updated emergency contact for you. Please list the person’s first and last name, relationship and phone number(s) of your emergency contact:
Full Name Relationship Number(s)
Please provide an address and cell phone number from where you are calling.
City State Zip Code
Cell Phone Number
If a situation occurs where we are talking and get disconnected and you are in crisis, you agree to call 911, go to your local emergency room immediately or contact the National Suicide Hotline at 800-273-8255.
If your therapist has concerns about your safety at any time during a phone session, she may break confidentiality and call 911 and/or your emergency contact immediately. Please note that everything in the informed consent that you signed, including all the confidentiality exceptions, still applies during video sessions.
Consent to Participate in Telehealth Sessions:
By signing below you agree that you have read and understand all of the above sections of telehealth informed consent. You agree that you also understand the limitations associated with participating in telehealth counseling sessions and consent to attend sessions under the terms described in this document.
Client or Parent/ Guardian Full Name