UPP Tele-Mental Health Informed Consent

Tele-Mental Health Informed Consent
Read the below information before moving on.
- I understand that my health care provider wishes me to engage in a Tele-Mental Health counseling session.
- My health care provider explained to me how the video conferencing technology that will be used to affect such a counseling session will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
- I understand that a Tele-Mental Health counseling session has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
- I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the tele-Mental Health counseling session if it is felt that the videoconferencing connections are not adequate for the situation.
- I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE TELE-HEALTH BY ZOOM SERVICE
Tele-health by Zoom is the technology service we will use to conduct tele-mental health video conferencing appointments. It is simple to use and there are no passwords required to login. Check the boxes below to acknowledge you understand:
Tele-health by Zoom is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
Though my provider and I may be indirect, virtual contact through the Tele-health Service, neither Zoom nor the Tele-health Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Tele-health by Zoom Service facilitates videoconferencing and is not responsible for the delivery of any health care, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in the Tele-health by Zoom Service– or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Tele-health by Zoom Service.
To maintain confidentiality, I will not share my tele-health appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:
- That I have read or had this form read and/or had this form explained to me.
- That I fully understand its contents including the risks and benefits of the procedure(s).
- That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
BY DIGITALLY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Clear
Thank you!
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Tele-Mental Health Informed Consent