1. I understand that Human Development Company has invited me to engage in a Telehealth appointment to provide assessment and short-term counseling.
2. My provider has explained to me that video conferencing technology will not be the same as a direct patient provider visit due to the fact that I will not be in the same room as my provider.
3. I understand that there are potential risks associated with use of this technology such as interruptions,technical difficulties, and inability to obtain information sufficient for decision making about my problem and that all possible precautions will be taken to minimize these risks. In addition, my provider or I can discontinue the Telehealth visit if it is felt that the information obtained through the telehealth connection is not adequate for decision-making or for implementing management of my issue(s). In that event, we will complete the session by phone or schedule an in-person appointment at the location where adequate assessment and short term counseling can be provided, I understand that the information I provide may be shared only with other individuals at my provider's office for scheduling purposes.
4.The alternatives to a Telehealth appointment/consultation have been explained to me.
By signing this form, I certify that:
•I have read or had this form explained to me.
•I fully understand its contents including the risks and benefits of the Telehealth appointment/consultation.
•I have been given ample opportunity to ask questions and that all questions have been answered to my satisfaction.
•I consent to this Telehealth appointment/consultation.
•I have been provided with HDC's Notice of Privacy Practices. Risks of using Email:Transmitting client information via email has possible risks that clients should consider. These includebut are not limited to, the following:
•Email can be circulated, forwarded, stored electronically and on paper, and broadcast tounintended recipients.
•Email senders can easily misaddress an email.
•Backup copies of email may exist even after the sender of the recipient has deleted his or her copy.
•Employers and on-line services have a right to inspect email transmitted through their systems.
•Email can be intercepted, altered, forwarded or used without authorization or detection.
•Email can be used to introduce viruses into computer systems.
Conditions for the use of Email:
The clinician cannot guarantee but will use reasonable means to maintain security and confidentialityof email information sent and received. The client and clinician must consent to the following conditions:
•Email is not appropriate for urgent or emergency situations. The client should schedule anappointment if the issue is too complex or sensitive to discuss via Email.
•Email communications between client and clinician will be filed in the client’s record.
•The client’s messages may also be delegated to another clinician or staff member for response.
•The clinician will not forward client-identifiable emails outside of HDC/CAL without the client’s priorwritten consent, except as authorized or required by law.
•It is the client’s responsibility to follow up and/or schedule an appointment if warranted.
I acknowledge that I have read and fully understand this consent form. I understand the possible risksassociated with the communication of email between the clinician and me. I consent to the conditionsand instructions outlined here, as well as any other instructions that the clinician may communicate with me by email. I agree to use the pre-designated email address specified above.Any questions I may have had were answered.