Consent to Therapy/Coaching/Telemental Health
I understand that I have the following rights with respect to In-person counseling, Coaching, and Telemental health:
1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
2. The laws that protect the confidentiality of my medical information also apply to telemental health and in-person counseling; FLY Counseling has also extended this confidentiality to Coaching clients as well. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
3. Cancellations and 'No call, no show' FEES:
If you need to reschedule your booked session, you have up until 24 hours before the date of your scheduled session.
PLEASE NOTE: In the event of a 'no call, no show' on the date of your scheduled session, you will be assessed a flat rate of $25.00
4. UPDATE FOR TELEMENTALHEALTH:
I understand that telemental health services are completely voluntary and that I can withdraw this consent at any time.
I understand that none of the telemental health 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 telemental health, and that no information obtained in the use of telemental health that identifies me will be disclosed to other entities without my consent.
I understand that telemental health 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 the therapist and practice 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 telemental 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 telemental health 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 telemental health 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 re - contact.
I understand a “no show” or late fee OF $25.00 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.
I understand my therapist will advise me about what telemental health platform to use and she will establish a video conference session.