Shasta College
Student Health & Wellness Office
P.O. Box 496006, 11555 Old Oregon Trail, Redding, CA 96049-6006
Phone: (530)242-7580 / Fax: (530) 225-4968
www.shastacollege.edu/wellness
I Drive > Wellness > Telehealth > TH Consents & Checklists > FILLABLE 2020 Telehealth Informed Consent
CONSENT FOR TELEHEALTH CONSULTATION AND TREATMENT
Client Full Name:
Client Location for Sessions (full address):
Student ID:
Current Phone:
This document is an addendum to the Shasta College Student Health & Wellness Office standard informed consent and does not
replace it. All aspects of informed consent for treatment in that document apply to TeleHealth (TH) treatment.
In California, “Telehealth” is defined as a method to deliver health care services using information and communication technologies
to facilitate the diagnosis, consultation, treatment, and care management while the patient and provider are at two different
sites. The two most common modes of telehealth are via 1) telephone, and 2) live videoconferencing either through a personal
computer with a webcam or a mobile communications device with two-way camera capability.
I understand that I have the following rights with respect to TeleHealth:
1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or
risking the loss or withdrawal of any benefits to which I would otherwise be entitled.
2) The laws that protect the confidentiality of my clinical information also apply to TH.
3) The laws regarding limits of confidentiality and mandated reporting also apply to TH.
4) I understand that the same laws that give me the right to access my clinical information and copies of treatment records
also apply to TH.
I understand the following potential benefits and risks, consequences, or limitations of TeleHealth:
TH can improve access to care as geographical distances, childcare issues and transportation challenges are virtually
eliminated.
TH may not be appropriate if you are having a medical emergency, crisis, acute psychosis, or suicidal or homicidal thoughts.
TH may lack visual and/or audio cues, which may increase the likelihood of misunderstanding each other.
TH may have disruptions or delays in the service and quality of the technology used.
In rare cases, there are risks associated with transmitting information via technology as security protocols could fail. These risks
include but are not limited to, breaches of confidentiality and theft of personal information. I understand the following backup plan
in case of technology failure:
The most reliable backup is a phone. Therefore, it is necessary that you always have a phone available and that your
provider knows your phone number.
If you get disconnected from a TH appointment;
o First, try to end and then restart the appointment.
o If you are unable to reconnect within five minutes, your provider will call you at the phone number you
provided at the beginning of each appointment.
Shasta College
Student Health & Wellness Office
P.O. Box 496006, 11555 Old Oregon Trail, Redding, CA 96049-6006
Phone: (530)242-7580 / Fax: (530) 225-4968
www.shastacollege.edu/wellness
I Drive > Wellness > Telehealth > TH Consents & Checklists > FILLABLE 2020 Telehealth Informed Consent
o If you are unreachable at this point, please call or email to reschedule non-urgent appointm
ents.
o If your provider assesses any urgent safety issues, they will immediately follow up with initiation of emergency
protocols.
EMERGENCY CONT
ACT
If you are experiencing an emergency, including a mental health crisis, please call 911, or the Suicide Prevention Hotline 1-800-273-
8255, or text “courage” to 741741 or go to your nearest emergency room.
So that your provider is able to get you help in the case of an emergency, the following are important and necessary. By signing this
agreement form you are acknowledging that you understand and agree to the following:
You must inform your provider of your location at the beginning of each appointment.
You must identify a person who can be contacted in the event that your provider believes your safety is at risk.
PATIENT RESPONSIBILITIES: By participating voluntarily in TeleHealth, you agree to comply with the following terms:
You will only engage in appointments when you are physically located in California. Your provider will ask you to confirm
this at the start of each appointment.
You will provide a valid government issued photo ID (driver's license, state issued ID, etc.) at the beginning of each
appointment. This is required to protect your identity / confidentiality. If unable to do so, your appointment will be re-
scheduled.
You are responsible for the privacy and security of the location where you choose to engage in Telehealth appointments.
You are responsible for ensuring private and confidential information regarding your health is not overheard or interrupted
by unauthorized persons.
You are responsible for the security of any computer or device you use to engage in a Telehealth appointment. You are
advised against using any publicly accessible computer or device to engage in a Telehealth appointment. You understand if
you use a public or employer computer you may compromise your privacy.
You are responsible for the security of any internet connection you use to engage in a Telehealth appointment. You are
advised to use only private internet connections or public connections in conjunction with a Virtual Private Network service.
You are responsible for the functionality and security of any computer or device you use, including installation of
appropriate operating systems and anti-virus software.
You will not make any audio, video, or other digital recording of any appointment.
Shasta College Student Health & Wellness Office will not make any audio, video, or other digital record of your
appointments without your written consent.
Signature of client:
Date:
Emergency Contact (Name, Relationship and Number):
Person of Support (Name, Relationship and Number) if different from above:
ACKNOWLEDGEMENTS
I acknowledge and understand the attendant risks involved with TH and voluntarily and willingly assume those risks as a
condition of participating.
I have read and understand the information provided above. I have discussed it with my provider and all of my questions have
been answered to my satisfaction.
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