INFORMED CONSENT TELE-THERAPY SERVICES
I understand that RJimenez Counseling Inc will provide mental health services which include assessment, diagnosis, therapy, follow-up and/or education; teletherapy consultations, treatment, transfer of personal and health information, emails, telephone conversations and education using interactive audio, video and data communications (“Telehealth”). Telehealth involves the use of electronic communications. I hereby consent to engage in Telehealth services with the LMHP.
I understand that the expected benefits of Telehealth are improved access to medical care, enabling me to remain at a remote site while the LMHP is at a distant site, more efficient evaluation and management, and obtaining the expertise of a distant specialist who is licensed in the state where I reside.
I understand and agree that this website is not an emergency-response or emergency-monitoring service, and any person who is aware of an emergency or believes that a person may be at risk of injury or death or who may harm themselves or another person should immediately contact an appropriate emergency responder or dial “911” on a phone. Rjimenez Counseling Inc. is under no obligation to monitor or respond to communications made to, on, or through this website. No user or person should rely on the website for medical or behavioral health advice or emergency services.
I understand that I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my personal and health information for in-person behavioral health services. Any information disclosed by me during the Telehealth session is generally confidential to the extent provided by law.
As with any medical care, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to:
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In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate professional decision-making by the LMHP.
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Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment.
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The possibility of disruption, distortion, or unauthorized access during transmission of personal information due to internet/electronic/technical failures beyond the control of Rjimenez Counseling and the LMHP.
By signing this form, I understand the following:
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I understand that Telehealth is the use of electronic communication technologies by a health and therapeutic provider to deliver services to an individual when they are located at a different site than the provider. I give my consent to the LMHP to provide mental health services to me via Telehealth.
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I understand that I may be required to have specific system requirements to access electronic Telehealth services via the method chosen. I know I am solely responsible for any cost to obtain additional/necessary system requirements, accessories, or software.
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I understand that I have the right to withhold or withdraw my consent to the use of Telehealth by the LMHP at any time without affecting my right to future care or treatment.
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I understand that a variety of alternative methods of health care may be available to me and that I may choose one or more at any time.
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I represent and warrant that all required information I provided to RJimenez Counseling Inc is truthful and accurate and that I will maintain the accuracy of such information.
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I understand that there are, by law, exceptions to confidentiality by a LMHP including, but not limited to, reporting child, elder and dependent adult abuse; expressed threats of violence toward an ascertainable victim; my own mental or emotional state informing a clear danger to myself or others; where I make my mental or emotional state an issue in a legal proceeding; where otherwise required by law.
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I understand that I am solely responsible for the privacy and confidentiality in my surrounding environment while engaged in Telehealth and will exercise appropriate privacy measures.
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I agree that if it becomes clear to the LMHP, in his or her sole professional opinion, that the Telehealth modality is unable to provide all pertinent clinical information during the Telehealth encounter, the LMHP will advise me before the conclusion of the live Telehealth encounter and will advise me regarding the need for me to obtain an additional in-person evaluation reasonably able to meet my needs and may make a referral to an LMHP in my area.
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I understand that I must inform my LMHP of electronic interactions regarding my care that I may have with other healthcare providers.
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I understand that Telehealth services may not be as complete as face-to-face services. I know that there are potential risks and benefits associated with any form of treatment, and despite my efforts and my LMHP, my condition may not improve and, in some cases, even worsen.
Note: This section below only applies for Immigration MH cases
Release of Information and Transmission of your Immigration MH Report
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I have authorized RJimenez Counseling to release information and the transmission of my Immigration MH Report to my immigration attorney.
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This serve as a "Release of Information" form which will allow the assessor to discuss your situation with anyone that would be of use in establishing your case (attorney, physician, etc.).
I have read and understand the information provided above regarding tele-therapy and all of my questions have been answered to my satisfaction.