Telemental Health Release

Information and Informed Consent for Telemental Health Treatment

Telemental health is the use of telecommunications or videoconferencing technology to provide mental health services.

Client Understanding

• I understand that telemental health services are completely voluntary and that I can withdraw this consent at any time.
• I understand that none of the telemental health sessions will be recorded or photographed. I agree not to make or allow audio or video recordings of any portion of the sessions.
• I understand that the laws that protect privacy and the confidentiality of client information also apply to telemental health, and that no information obtained in the use of telemental health that identifies me will be disclosed to other entities without my consent.
• I understand that telemental health is performed over a secure communication system that is almost impossible for anyone else to access. I understand that any internet based communication is not 100% guaranteed to be secure. I agree that Elisa Elkin-Cleary, LICSW, will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that myself or my therapist may discontinue the telemental sessions at any time if it is felt that the video technology is not adequate for the situation.
  I understand that if there is an emergency during a telemental health session, then my therapist may call emergency services and/or my emergency contact.
• I understand that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and that all office policies and procedures apply to telemental health services.
• I understand that if the video conferencing connection drops while I am in a session, I will have an additional phone line available to contact my therapist, or I will make additional plans with my therapist ahead of time for re-contact.
• For long distance video consultations and personal work, Ms. Elisa Elkin-Cleary uses encrypted video conferencing software from Zoom. Her Business Associate Agreement with Zoom Video Communications complies with relevant Federal and State confidentiality standards, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). The Health Insurance Portability and Accountability Act (“HIPAA”) protects the medical information and records of patients and may apply to information disclosed during the course of the counseling process.
• By signing below, I consent to the use of secure video personal work and consulting and agree that Ms. Elisa Elkin-Cleary will not be liable for disclosures in violation of HIPAA resulting from video counseling. I further agree that I will not seek to hold Ms. Elkin-Cleary liable for any such violations and that I personally bear the risk of disclosure of my protected medical information and records.

Client Information

Emergency Contact Information