Counseling Connections
Counseling Connections 2016
Telemental Health Informed Consent
As a client receiving behavioral services through telehealth methods, I understand:
elemental health is the delivery of behavioral health services using interactive technologies
(audio, video or other electronic communications) between a provider and a client that are not in
the same physical location. The interactive technologies used in Telemental health incorporate
network and software security protocols to protect the confidentiality of patient information
transmitted via any electronic channel. These protocols include measures to safeguard the data
and to aid in protecting against intentional or unintentional corruption. 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.
1. T
his service is provided by technology (included but not limited to video, phone, text
ail) and may involve direct face to face communication. There are benefits and
limitations to this service. I will need access to, and familiarity with, the appropriate
technology in order to participate in the service provided. The exchange of informati
ill not be direct and any paperwork exchanged will likely be provided through electronic
means or through postal delivery. During your virtual care consultation, details of your
medical history and personal health information may be discussed with you or your
behavioral health care professionals through the use of interactive video, audio or other
telecommunications technology.
2. I
f a need for direct, face to face services arises, it is my responsibility to contact
practitioners in my area such as _____________________, _____________________,
or ____________________ or to contact my behavioral health practitioner’s office for
ace to face appointment or my primary care provider if my behavioral health practitioner
is unavailable. I understand that an opening may not be immediately available in either
3. I
may decline any telehealth services at any time without jeopardizing my access t
uture care, services or benefits.
4. T
hese services rely on technology, which allows for greater convenience in servic
ivery. There are risks in transmitting information over technology that include, but ar
not limited to, breaches of confidentiality, theft of personal information, and disruption of
service due to technical difficulties. My practitioner and I will regularly reassess t
opriateness of continuing to deliver services to me through the use of t
echnologies we have agreed upon today, and modify our plan as needed.
5. I
n emergencies, in the event of disruption of services, or for routine or administrativ
reasons, it may be necessary to communicate by other means:
a. I
n emergency situations: _______________________________________________
b. Service disruption: ___________________________________________________
c. For other communication: ______________________________________________
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6. My practitioner may utilize alternative means of communication in the following
circumstances: video connections fail or phone line access is disrupted.
7. My practitioner will respond to communications and routine messages within 48 hours on
business days or on the next business day following weekends, holidays, or vacations.
8. I
t 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 hav
cess to records or communications.
9. I
will take the following precautions to ensure that my communications are directed only
to my behavioral health practitioner or other designated individuals: Double check email
addresses; double check phone numbers; double check to whom email is sent (reply vs
reply all).
10. M
y communication with my behavioral health practitioner will be stored in the following
manner: In compliance with HIPAA regulations in secured file cabinets and/or secured
electronic medical record files.
11. T
he laws and professional standards that apply to in-person behavioral services als
y to telehealth services. This document does not replace other agreements,
contracts, or documentation of informed consent.
Client Printed Name
_______________________________________ ____________
Signature of Client or Legal Guardian Date
mega J. Galliano, MFT, LADC, LP
Practitioner Printed Name
Signature of Practitioner Date
click to sign
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Addendum A
Client Name: ________________________________
I, the undersigned, a citizen of ______________________ or my designee(s) _____________
on my behalf, agree to participate in technology-based consultation and other health-care
related information exchanges with Omega J. Galliano, a behavioral healthcare practitioner
(“practitioner”). This means that I authorize information related to my medical and behavioral
health to be electronically transmitted in the form of images and data through an interactive
video connection to and from the above-named practitioner, other persons involved in my health
care, and the staff operating the consultation equipment. It may also mean that my private
health information may be transmitted from my practitioner’s mobile device to my own or from
my device to that of my practitioner via an ‘application’ (abbreviated as “app”).
You understand that a variety of alternative methods of mental health care may be available to
you, and that you may choose one or more of these at any time. Your mental health care
provider has explained the alternative to your satisfaction.
I represent that I am using my own equipment to communicate and not equipment owned by
another, and specifically not using my employer’s computer or network. I am aware that any
information I enter into an employer’s computer can be considered by the courts to belong to my
employer and my privacy may thus be compromised.
I understand that I will be informed of the identities of all parties present during the consultation
or who have access to my personal health information and of the purpose for such individuals to
have such access.
My health care practitioner has explained how the telehealth consultation(s) is performed and
how it will be used for my treatment. My health care practitioner has also explained how the
consultation(s) will differ from in-person services, including but not limited to, emotional
reactions that may be generated by the technology.
You understand that it is your duty to inform your physician of electronic interactions regarding
your care that you may have with other health care providers.
In brief, I understand that my practitioner will not be physically in my presence. Instead, we will
see and hear each other electronically, or that other information such as information I enter into
an “app” will be transmitted electronically to and from my practitioner and I. Regardless of the
sophistication of today’s technology, some information my practitioner 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 practitioner to understand my
problems and to help me get better. My practitioner will be unable to physically touch me or to
render any emergency assistance if I experience a crisis.
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I understand that telehealth consultation(s) are a new form of treatment, in an area not yet fully
validated by research, and that they 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 the consultation, that the transmitted information in any form
will be unclear or inadequate for proper use in the consultation(s), and that the information will
be intercepted by an unauthorized person or persons.
In rare instances, security protocols could fail, causing a breach of privacy of personal health
information. I understand that a physical examination may be performed by individuals at my
location at the request of the consulting practitioner.
I authorize the release of any information pertaining to me determined by my practitioner, my
other health care practitioners or by my insurance carrier to be relevant to the consultation(s) or
processing of insurance claims, including but limited to my name, Social Security number, birth
date, diagnosis, treatment plan and other clinical or medical record information.
I understand that at any time, the consultation(s) can be discontinued either by me or by my
designee or by my health care practitioners. I further understand that I do not have to answer
any question I feel is inappropriate or whose answer I do not wish persons present to hear; that
any refusal to participate in the consultation(s) or use of technology will not affect my continued
treatment and that no action will be taken against me. I acknowledge, however, that diagnosis
depends on information, and treatment depends on diagnosis, so if I withhold information, I
assume the risk that a diagnosis might not be made or might be made incorrectly. Were that to
happen, my telehealth-based treatment might be less successful than it otherwise would be, or
it could fail entirely.
I also understand that, under the law< and regardless of what form of communication I use in
working with my practitioner, my practitioner may be required to report to the authorities
information suggesting that I have engaged in behaviors that endanger others.
The alternatives to the consultation(s) have been explained to me, including their risks and
benefits, as well as the risks and benefits of doing without treatment. I understand that I can still
pursue in-person consultations. I understand that telehealth consultation(s) does not
necessarily eliminate my need to see a specialist in person, and I have received no guarantee
as to the telehealth consultation’s effectiveness.
I understand that my telehealth consultation(s) may be recorded and stored electronically as
part of my medical records. The practitioner will inform me if this is to occur and the reasons for
this being necessary. I understand that consultations, test results, and disclosures will be held
in confidence subject to state and/or federal law. I understand that I am ordinarily guaranteed
access to my medical records and that copies of records of consultation(s) are available to me
on my written request. I also understand, however, that if my practitioner, in the exercise of
professional judgment, concludes that providing my records to me could threaten the safety of a
human being, myself or another person, he/she may rightfully decline to provide them. If such a
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request is made and honored, I understand that I retain sole responsibility for the confidentiality
of the records released to me and that I may have to pay a reasonable fee to get a copy.
Additionally, I understand that my records may be used for telehealth program evaluation,
education, and research and that I will not be personally identified if such a use occurs. I
hereby authorize these disclosures to take place without prior written consent.
I understand that I am not entitled to royalties or to other forms of compensation for participation
in any telehealth consultation(s) or information exchange.
I have received a copy of my practitioner’s contact information, including his/her name,
telephone number, business address, mailing address, and email address (if applicable). I have
also been provided with a list of local support services in case of an emergency. I am aware
that my practitioner may contact the proper authorities and/or my designated local contact
person in case of an emergency.
I acknowledge, however, that 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 telehealth consultation.
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).
Name Relationship Telephone number
Name Relationship –Telephone number
Name Relationship Telephone number
Name Relationship Telephone number
Name Relationship Telephone number
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I unconditionally release and discharge Omega J. Galliano and Counseling Connections, its
affiliates, agents and employees; and any other organization involved in the remote
consultation(s) from any liability in connection with my participation with telehealth remote
I have read this document carefully and fully understand the benefits and risks. I have had the
opportunity to ask questions I have and received satisfactory answers. With this knowledge, I
voluntarily consent to participate in the telehealth videoconference consultation(s), including but
not limited to any care, treatment, and services deemed necessary and advisable, under the
terms described herein.
_____________________________ ____________ _______________________
Name Date Witness
The above release is given on behalf of ___________________________ because the patient
in a minor or has been determined to be incompetent to give medical consent for the following
reasons: ___________________________________________________________________
____________________________ ____________ ___________________
Parent or Legal Guardian Date Time