Consent for Teletherapy
Teletherapy involves the use of electronic communications to enable therapists to see their clients for regular sessions from their home.
The Center for Music Therapy and Wellness will use the HIPPA approved application doxy.me, Google Duo and ZOOM for Teletherapy sessions.
The informatin may be used for therapy, follow-up and/or education, and may include any of the following:
- Patient medical records
- Live two-way audio and video
- Sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure it's integrity against intentional or unintentional corruption.
Expected Benefits:
- Continuing of music therapy services
- Working towards treatment goals and objectives
- Maintaining the therapeutic relationship
- Continuity of scheduled activities
Possible Risks:
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
Client Name*
First Name Last Name
Therapist Name*
First Name Last Name
Guardian Name*
First Name Last Name
Diagnosis*
Email*
example@example.com
Date of Birth*
Month Day Year
Date
Phone Number*
Area Code Phone Number
By signing this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to teletherapy, and that no information obtained in the use of teletherapy which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of teletherapy in the course of my care at any time, withoutaffecting my right to future care or treatment.
3. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one of more of these at any time. My music therapist has explained te alternatives to my satisfaction.
4. I understand that I may expect the anticipated benefits from the user of teletherapy in my care, but that no results can be guaranteed or assured.
Patient Consent to The Use of Teletherapy
I have read and understand the information provided above regarding teletherapy, have discussed it with my music therapist, and all of my questions have been answered to my satifsfaction.
I hereby give my informed consent for the use of teletherapy in my music therapy treatment.
I hereby authorize {therapistName} to use teletherapy in the course of my treatment.
Signature of Patient (or person authorized to sign for patient):*
Clear
Signature Date:
Month Day Year
Date
If authorized signer, relationship to client
Should be Empty:

Consent for Teletherapy