• New London, Newport, Claremont & the Upper Valley

Telebehavioral Health Informed Consent

Telebehavioral Health Information:
  • As a client receiving behavioral health services through telebehavioral health technologies, I understand:
    • Telebehavioral health is the delivery of behavioral health services using interactive technologies (use of video conferencing) between a therapist and a client who are not in the same physical location.
    • The interactive technologies used in telebehavioral health incorporate network and software security protocols to protect the confidentiality of client information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.
Software Security Protocols:
  • Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.
Technology Requirements:
  • will need access to, and familiarity with, the appropriate technology in order to participate in the service provided. This technology will be provided to me and set up for me at the satellite office where I will be scheduled to present for video conferencing with my therapist if I am presenting to an office. The administrative staff at the satellite location will be available to assist me with technology set up and login as well as address any questions that may occur during my appointment.
  • If I am meeting with my therapist from home I am responsible for the technology that I am choosing to use. My therapist will be at a different location.
Benefits & Limitations:
  • This service is provided by technology (including but not limited to video, phone, and email) and may not involve ongoing direct face-to-face communication. There are benefits and limitations to this service including increased access to care. A face-to-face intake session is required for care.
  • Regardless of the sophistication of today's technology, some information my therapist would ordinarily get in in-person consultation may not be available in teleconsultation. I understand that such missing information could in some situations make it more difficult for my therapist to understand my problems and to help me get better. My therapist will be unable to render any direct emergency assistance if I experience a crisis however, will utilize and contact identified local emergency services and supports if necessary.
Risks of Technology:
  • These services rely on technology, which allows for greater convenience in service delivery. There are risks transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.
  • I understand that telebehavioral health is a new delivery method for professional services, in an area not yet fully validated by research, and may have potential risks, possibly including some that are not yet recognized.
  • Among the risks that are presently recognized is the possibility that the technology will fail before or during consultation, that the transmitted information in any form will be unclear or inadequate for proper use in treatment, and that the information may be intercepted by an unauthorized person or persons.
  • In rare instances, security protocols could fail, causing a breach of privacy of personal health information.
Exchange of Information:
  • The exchange of information will often times not be direct and paperwork exchanged may at times be provided through electronic means or through postal delivery.
  • During my telebehavioral health treatment, details of my medical history and personal health information may be discussed through the use of interactive video, audio, or other telecommunications technology.
Storage:
  • My communication exchanged with my therapist will be stored in my confidential electronic medical record. This includes any emails exchanged. Video conferencing sessions will not be recorded or stored.
Local Practitioners:
  • If a need for direct, in-person services arises, it is my responsibility to contact practitioners in my area or to contact my therapist's office for an in-person appointment. I understand that an opening may not be immediately available in either office.
Emergency Protocol:
  • In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means:
    • In emergency situations you may be contacted by phone and/or your emergency contact may be contacted in order to ensure your safety and wellbeing.
    • In emergency situations it also may be necessary to contact authorities, emergency contact, PCP, and or any other emergency personnel to ensure your safety and wellbeing.
  • I acknowledge, that if I am facing or if I think I may be facing an emergency situation that could result in harm to me or to another person; I am not to seek a telebehavioral health session. Instead, I agree to seek care immediately through my own local health care practitioner or at the nearest hospital emergency department or by calling 911.
These are the names and telephone numbers of my local emergency contacts (including local physician, crisis hotline, trusted family, friend, or adviser).

NameTelephone Number
NameTelephone Number
NameTelephone Number

Email To Receive Invitations to Participate In Sessions:
  • In order to take part in telehealth services it is necessary to provide an email for which you are comfortable receiving your invitation links to participate in sessions. Please provide your preferred email below. Providing your email authorizes Counseling Associates to send your meeting invitations to this email.
Email 

Disruption of Service:
  • Should service be disrupted please ask the administrative staff member available on site for assistance. Your therapist may also contact the administrative staff member at your site to assist with correcting any technical difficulties in order to continue the session. If services cannot be restored it may be necessary to connect via phone to complete session and/or reschedule session for another day/time.
Therapist Communication:
  • My therapist will respond to communications and routine messages in a timely manner however, voicemail, email, and any other indirect/unscheduled messaging service should not be used in the case of an emergency.
Client Communication:
  • It is my responsibility to maintain privacy on the client end of communication. Insurance companies, those authorized by the client, and those permitted by law may also have access to records or communications.
Electronic Presence:
  • I understand that my therapist will not be physically in my presence. Instead, we will see and hear each other electronically.
Modification & Treatment Plan:
  • My therapist and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of technology and modify our plan as needed.
Self-Termination & Discontinuing Care:
  • I may decline any telebehavioral health services at any time without jeopardizing my access to future care, services, and benefits.
  • I understand that at any time, telehealth treatment can be discontinued either by me or by my therapist.
  • It is strongly encouraged that a termination session be scheduled and held.
Release of Liability:
  • I unconditionally release and discharge Counseling Associates, its affiliates, agents, and employees as well as my therapist and his or her designees from any liability in connection with my participation in remote counseling services.
Laws & Standards:
  • The laws and professional standards that apply to in-person behavioral health services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.
Final Agreement:
  • I have read this document carefully and fully understand the benefits and risks. I have had the opportunity to ask any questions I have and have received satisfactory answers.
  • With this knowledge, I voluntarily consent to participate in the telebehavioral consultation(s), including but not limited to any care, treatment, and services deemed necessary and advisable, under the terms described herein.

Confirmation of Agreement:
Client Printed Name  
Signature of Client or Legal Guardian Date
Printed Name of Therapist 
Signature of Therapist Date