Skip to main content
INTRODUCTION This document provides information about telehealth services offered by our practice, the associated risks and benefits, and your rights and responsibilities as a client. Please read this document carefully and discuss any questions you may have. DEFINITION OF TELEHEALTH Telehealth refers to the provision of healthcare services remotely using telecommunications technologies such as video conferencing. This allows you and your provider to connect using interactive video and audio communications when you are not in the same physical location. CONSENT FOR TELEHEALTH CONSULTATION
  1. I understand that my healthcare provider wishes me to engage in a telehealth consultation.
  2. My healthcare provider has explained to me how the video conferencing technology that will be used for this consultation will not be the same as a direct client/healthcare provider visit due to the fact that I will not be in the same room as my provider.
  3. I understand that a telehealth consultation has potential benefits including easier access to care, convenience of meeting from a location of my choosing, and reduced travel time.
  4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth visit if it is felt that the videoconferencing connections are not adequate for the situation.
  5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions regarding 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.
LICENSURE INFORMATION Under state regulations, your therapist is only permitted to provide telehealth services to clients physically located in the state(s) where they hold a license at the time of service. TELEHEALTH PLATFORM AND TECHNOLOGY REQUIREMENTS We use Jane, a HIPAA-compliant platform designed for healthcare providers. This platform utilizes encryption and other security measures to protect your privacy. You will receive instructions on how to access this platform prior to your first telehealth session. To participate in telehealth sessions, you will need:
  • A computer, tablet, or smartphone with a camera and microphone
  • A stable internet connection with sufficient bandwidth (at least 1 Mbps upload/download speed)
  • A private, quiet space where you will not be interrupted or overheard
  • A secure, updated web browser
  • Headphones (recommended for improved audio quality and privacy)
Prior to your first appointment, we recommend testing your equipment to ensure compatibility with our telehealth platform. CONSENT TO USE THE TELEHEALTH SERVICE Jane is the technology service we will use to conduct telehealth videoconferencing appointments. By signing this document, I acknowledge:
  1. This telehealth service is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
  2. Though my provider and I may be in direct, virtual contact through the telehealth service, neither the telehealth service provider nor the platform provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
  3. The telehealth service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice, or care.
  4. I do not assume that my provider has access to any or all of the technical information in the telehealth service – or that such information is current, accurate, or up-to-date. I will not rely on my healthcare provider to have any of this information in the telehealth service.
  5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
BENEFITS AND RISKS OF TELEHEALTH Benefits of telehealth Telehealth provides several potential benefits, including:
  • Increased accessibility to psychological care
  • Convenience and time efficiency
  • Reduced transportation barriers
  • Continuity of care regardless of physical location within licensed states
  • Reduced risk of exposure to contagious illnesses
  • Ability to receive services in the comfort of your own space
  • Increased access to care during situations that prevent in-person sessions
Potential risks of telehealth As with any healthcare service, there are potential risks associated with telehealth, including:
  1. Technology failures: Sessions may be disrupted by technology failures, such as internet outages, computer crashes, or software issues.
  2. Reduced visual and non-verbal cues: Your therapist may have less ability to read body language and non-verbal cues compared to in-person sessions.
  3. Privacy and security risks: Despite our best efforts to ensure confidentiality, telehealth platforms can never be 100% secure. There is a risk of unauthorized access to sensitive information transmitted electronically.
  4. Emergency situations: It may be more difficult for your therapist to provide immediate assistance in the event of a crisis or emergency during a telehealth session.
  5. Insurance coverage: Some insurance plans may not cover telehealth services or may provide reduced coverage.
STEPS WE TAKE TO ADDRESS THESE RISKS
  1. We use HIPAA-compliant, encrypted video platforms specifically designed for healthcare.
  2. We conduct sessions only in private, secure locations and expect the same from you.
  3. We have established protocols for managing technical difficulties and emergency situations.
  4. We maintain the same documentation standards as for in-person sessions.
  5. We verify your identity and location at the beginning of each session.
CLIENT RESPONSIBILITIES FOR TELEHEALTH SESSIONS As a telehealth client, you agree to:
  1. Provide your location: At the beginning of each session, you will need to inform your therapist of your physical location (full address). This information is crucial in case of an emergency.
  2. Be in a state where your therapist is licensed: You confirm that you will only participate in telehealth sessions when physically located in a state where your therapist is licensed to practice.
  3. Identify an emergency contact: You will need to provide the name and contact information of a local support person who may be contacted in case of an emergency.
  4. Maintain privacy: You are responsible for ensuring that your physical environment is private and secure. Sessions should not be conducted in public places or where others may overhear.
  5. Do not record sessions: You agree not to record telehealth sessions without prior written consent from your therapist.
  6. Be present and engaged: You should be fully present during sessions, not engaging in other activities such as driving, operating machinery, or multi-tasking.
  7. Test your equipment: You are responsible for testing your equipment before sessions and informing your therapist of any technical issues.
  8. Have a backup plan: In the event of technical failures, you and your therapist should have a backup plan (e.g., continuing the session by phone).
THERAPIST RESPONSIBILITIES FOR TELEHEALTH SESSIONS Your therapist agrees to:
  1. Maintain the same ethical standards: All ethical standards that apply to in-person therapy also apply to telehealth.
  2. Maintain confidentiality: Your therapist will conduct sessions in a private location where others cannot see or hear you.
  3. Provide technical support: Your therapist will help troubleshoot basic technical issues when possible.
  4. Have emergency protocols: Your therapist will have established protocols for managing emergencies during telehealth sessions.
  5. Provide alternative options: If telehealth is not appropriate for your needs, your therapist will discuss alternative options.
  6. Follow state regulations: Your therapist will adhere to all telehealth guidelines set by state licensing boards and federal regulations.
EMERGENCY PROTOCOLS FOR TELEHEALTH SESSIONS In case of an emergency during a telehealth session:
  1. If the session is disrupted and you are in crisis, your therapist will call you on the phone number you have provided.
  2. If your therapist cannot reach you and they have reason to believe you are in danger, they may contact your emergency contact person or local emergency services.
  3. If you experience a life-threatening emergency, you should call 911 or go to your nearest emergency room, then contact your therapist when it is safe to do so.
  4. Local crisis resources:
  • National Suicide Prevention Lifeline: 988 or 1-800-273-8255
  • Crisis Text Line: Text HOME to 741741
  • Local Crisis Line: 988
APPROPRIATENESS OF TELEHEALTH Not all situations are appropriate for telehealth. Your therapist will continually assess whether telehealth is appropriate for your circumstances. Factors that may make telehealth inappropriate include:
  • Severe or acute psychiatric conditions requiring intensive support
  • Active suicidal or homicidal thoughts with intent
  • Certain mental health diagnoses or symptoms that may be better treated in person
  • Lack of access to necessary technology
  • Cognitive impairments that limit ability to use technology
If at any point your therapist determines that telehealth is no longer appropriate, they will discuss alternative options with you. TECHNICAL DIFFICULTIES If technical issues occur during a telehealth session:
  1. Your therapist will attempt to reconnect for up to 5 minutes.
  2. If reconnection is not possible, your therapist will call you at the phone number you have provided.
  3. If a session is significantly disrupted by technical issues, options may include:
  • Continuing the session by phone
  • Rescheduling the remainder of the session
  • Prorating the session fee based on the time completed
FEES AND PAYMENT FOR TELEHEALTH
  • Telehealth sessions are billed at the same rate as in-person sessions: $150 per 60 minute session.
  • The same cancellation policy applies to telehealth sessions as in-person sessions.
  • Insurance coverage for telehealth services varies by provider, plan, and state.
  • It is your responsibility to verify whether your insurance plan covers telehealth services.
  • You are responsible for any costs not covered by your insurance.
  • We accept all major credit or debit cards for telehealth sessions.
INSURANCE AND TELEHEALTH
  • Some insurance companies cover telehealth services the same as in-person sessions, while others have different coverage or limitations.
  • Some states have “telehealth parity laws” requiring insurance companies to cover telehealth services the same as in-person services, but exceptions may apply.
  • We recommend contacting your insurance provider directly to verify your telehealth benefits before your first telehealth session.
  • Our office can assist with verifying active coverage, but ultimately, you are responsible for understanding your insurance coverage.
TELEHEALTH ACROSS STATE LINES Under current regulations, your therapist can only provide telehealth services to clients who are physically located in the state(s) where they hold a professional license. If you plan to participate in sessions from a different state, please inform them in advance so they can determine whether they are legally permitted to provide services in that location. In some cases, temporary practice across state lines may be possible under:
  • Interstate compacts, if applicable to their profession and the states involved.
  • Temporary practice provisions that some states enacted during the COVID-19 public health emergency (some of which may still be in effect).
  • Special licensure or registration provisions that allow for limited interstate practice.
If you will be traveling to a state where your therapist is not licensed to practice, we will need to either:
  • Reschedule your appointment for when you return to a state where your therapist is licenced to practice.
  • Refer you to a local provider in your temporary location if you need services during that time.
ELECTRONIC COMMUNICATION
  • Email and phone communications are not completely secure or confidential.
  • Email and phone should be used only for administrative purposes (scheduling, billing questions), not for therapeutic exchanges.
  • Any emails you send to me may become part of your legal medical record.
  • I will not follow or accept friend/connection requests from clients on social media platforms.
CONFIDENTIALITY IN TELEHEALTH The same confidentiality protections that apply to in-person sessions apply to telehealth sessions. However, there are some additional considerations specific to telehealth:
  1. It is your responsibility to ensure that your physical environment during telehealth sessions is private and secure.
  2. There are inherent privacy risks with any technology-based service, despite our use of HIPAA-compliant platforms and security measures.
  3. Your therapist will inform you if anyone else is present at their location during a telehealth session, and likewise expects you to inform them if anyone else is present at your location.
  4. In the event of technical difficulties that compromise the privacy of a session, your therapist may choose to terminate the session and continue via telephone or reschedule.
USE OF AI IN TELEHEALTH Jane AI Scribe is used during telehealth to assit in your therapists “psychotherapist notes” by transcribing the telehealth session. Jane AI Scribe is HIPAA, PIPEDA and PHIPA compliant. Your data is never used to train AI models. Additional information can be found within the Notice of Privacy Practices. CERTIFICATION AND AGREEMENT 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 telehealth services.
  • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
  • I understand that I can withdraw my consent to telehealth services at any time.
  • I understand that the same confidentiality protections, limits to confidentiality, and rules around my access to records apply to telehealth as they do to in-person services.
  • I certify that I will be physically located in a state where my provider is licensed during all telehealth sessions.