Telehealth Consent: Doña Ana

FOR DOÑA ANA COUNTY ONLY. Intake forms are securely encrypted and HIPAA compliant.
  • Telehealth Consent: Doña Ana
    ID #
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  • I hereby consent to engage in teletherapy with Southwest Family Guidance Center, LLC. Teletherapy is a form of psychological service provided via internet technology, which can include consultation, treatment, transfer of medical data, emails, telephone conversations and/or education using interactive audio, video, or data communications. I also understand that teletherapy involves the communication of my medical/mental health information, both orally and/or visually.

    Teletherapy has the same purpose or intention as psychotherapy or psychological treatment sessions that are conducted in person. However, due to the nature of the technology used, I understand that teletherapy may be experienced somewhat differently than face-to-face treatment sessions.

    I understand that I have the following rights with respect to teletherapy:

    Client’s Rights, Risks, and Responsibilities

    1. I, the client, have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
    2. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are described in the Notice of Privacy Practices and other general client intake forms that I received at the start of my treatment with Southwest Family Guidance Center.
    3. I understand that there are risks and consequences of participating in teletherapy, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my provider, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted or intercepted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
    4. There is a risk that services could be disrupted or distorted by unforeseen technical problems.
    5. In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services. I also understand that if my provider believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I will be referred to a professional who can provide such services in my area.
    6. I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form ofpsychotherapy, and that despite my efforts and the efforts of my psychologist, my condition may not improve, and in some cases may even get worse.
    7. I accept that teletherapy does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the New Mexico Crisis Line at(855) 662-7474 or the National Suicide Prevention Lifeline at (800) 273-TALK (8255) for free 24 hour hotline support. Clients who are actively at risk of harm to self or others generally are not suitable for teletherapy services. If this is the case or becomes the case in future, my provider may, if necessary, recommend that I seek other service more appropriate to my particular circumstances.
    8. I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in teletherapy. I am responsible for (1) providing the necessary computer, telecommunications equipment, and internet access for my teletherapy sessions, and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session. It is the responsibility of my provider to do the same.
    9. I understand that dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.
    10. I understand that not all teletherapy sessions are recorded and stored.
    11.  All existing laws regarding access to my medical and mental health information and records apply to my teletherapy services.
    By signing below, I certify that:
    1. I have read, understand, and agree to the contents of this document,
    2. I understand the the benefits and risks of engaging in teletherapy services, and
    3. I consent to engaging in teletherapy services with Southwest Family Guidance Center.
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