The Details

Telehealth Informed Consent

Definition of Telehealth: Telehealth involves the use of electronic communications to enable Solomon Counseling LLC clinicians to connect with clients using live interactive video and audio communications. Telehealth includes the practice of psychotherapy health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

I understand that:

• The laws that protect the confidentiality of my personal information that I have already signed also apply to telehealth.

• I understand that I have the right to withhold or withdraw my consent for the use of telehealth in the course of my care at any time.

• I understand that there are risks with the use of telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the therapist, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be intercepted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Solomon Counseling LLC utilizes secure, encrypted, audio/video transmission software to deliver telehealth.

• I understand that certain situations, including emergencies and crises, are inappropriate for audio/video/computer based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

• I understand that I will need to have a private place to hold telehealth sessions, in which others who are not part of my treatment will not be able to hear or see the private information being discussed in session, and that if such a space is not available that we will have to reschedule the session.

• I understand that Solomon Counseling LLC’s standard cancellation policies will also apply to telehealth sessions.
  

Group Sessions

Although we use a secure telehealth platform, in the group setting there are additional risks that are important for you to be aware of and that you understand the group leader can not fully control for. By agreeing to participate in group via telehealth, you are agreeing to the following and understand that you are relying on group members to adhere to the following:

• Maintain a secure and private location for the entirety of group [to include no one else is in the room, or passing by the screen, within hearing distance of the audio, or within viewing ability of the screen]

• No recording of any kind during the session

• No photography of any kind during the session

• Not to share any group login information with anyone

• Maintain confidentiality as you would in the office setting

• Any group member that breaches confidentiality may be discharged from group.

Out of Network Insurance Reimbursement

Your insurance company may or may not cover telehealth services. If you do plan to seek reimbursement for telehealth services from your insurance company, please make sure to check with them on their coverage policies
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT, AND THAT I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN THE USE OF TELEHEALTH SERVICES FOR TREATMENT.