I am showing the following document to give you an idea of what you can expect with telehealth services. If you are interested in having video therapy sessions with me, please contact me. If we decide to work together, then I will include this consent form with the other forms I will ask you to complete.
CONSENT FOR TELEHEALTH SERVICES
WITH CHARLETTE MIKULKA, LCSW
Created March 2020
Telehealth or teletherapy is the mode of delivering health care services (psychotherapy, couple therapy) via information and communication technologies (e.g. phone or internet) to facilitate the diagnosis, consultation, treatment, education, care and management of a patient’s health care while the clinician and patient are not in the same physical location.
You should be aware that providing therapy in this manner has advantages and disadvantages. Here are some drawbacks or things to consider:
- Technical difficulties may impact the session. The connection may not be stable. Video can freeze, audio can be dropped and the connection may be lost. A wired connection to your mobile device is ideal, but if you must go wireless, it should be a very strong connection.
- You are responsible for making sure to have the latest operating system and security updates on the computer you want to use for telehealth sessions.
- The session may not be secure or confidential unless you make it so. The therapist will be located in a private space for your security and confidentiality and you too are encouraged to locate yourself in a place that you know is private and secure. For example, avoid initiating a session at a park, coffee shop or restaurant or any place where you will be interrupted, distracted or overheard.
- Telehealth does not provide emergency services. If you are experiencing an emergency situation, then the following are your options and you are responsible for accessing and utilizing necessary resources:
1. Call 911
2. Call a 24 hour Hotline: Newton Medical Center: 973-383-0973 or
3. Proceed to the nearest hospital emergency room.
- A therapist may miss certain visual cues during a telehealth session that may have been obvious at an in-person session. This could impact the therapist’s professional judgment of your condition.
The following are advantages to using telehealth as a medium for providing psychotherapy and couples therapy:
- You will be able to participate in therapy conveniently in the comfort of your own home
- You will be able to eliminate the time and cost of commuting to and from the therapist’s office
- You can schedule sessions around your work schedule
- Even if you are not feeling well enough to leave the house, you can still attend a telehealth session
- Your therapy will not be interrupted by common and uncommon causes of cancelled sessions- inclement weather, car trouble, sick child at home, disease outbreak (coronavirus), etc.
- With telehealth you are not limited to seeing a local therapist, as long as the therapist resides in the same State as you.
Additional expectations when using Telehealth:
- You should inform me immediately if any other person is present and can hear or see any part of our session.
- During a telehealth session both locations shall be considered a therapeutic consultation space, regardless of a room’s intended use.
- Neither I nor my telehealth client will ever record our sessions unless we have obtained explicit written consent.
- The Simple Practice Telehealth platform which I use meets federal (HIPAA) requirements for security and confidentiality
- The laws and professional standards that apply to in-person psychotherapy services also apply to telehealth services. This document does not replace the other Informed Consent Form for my practice that you have signed.
- Should we experience technical difficulties that prevent continuing the video session, I will immediately attempt to reconnect via telephone.
- If I determine that a client and I cannot sustain adequate audio-video connection and it is detrimental to providing competent therapeutic service, I will discontinue providing the telehealth service and another plan will be arranged.
- If I determine that a client is not being best served by telehealth and requires a different form of therapy, telehealth will be discontinued and a more suitable mode of therapy will be recommended.
- You most likely can use your health insurance benefits to pay for telehealth sessions, but your eligibility and benefits must be verified by you.
- You may benefit from telehealth services, but results, just as with in-person psychotherapy, cannot be guaranteed or assured.
- You have the right to withhold or withdraw consent to telehealth services at any time without jeopardizing your right to future care and services.
I have read and I understand the advantages and disadvantages of using telehealth for my mental health treatment or couple therapy. I understand what I can expect of telehealth therapy provided by Charlette Mikulka, LCSW. I have discussed the above document with Charlette Mikulka, LCSW and had all my questions answered to my satisfaction. I agree and consent to the use of telehealth for the treatment of my mental health and relationship concerns.