Informed Consent/Disclosure Statement - TELEHEALTH

This is to inform you of specific information for Telehealth Services, should you consider this option. This statement is to be included in addition to the standard informed consent/disclosure statement provided to you and not a stand alone agreement.

• There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.
• Confidentiality still applies for Telehealth services, and nobody will record the session without the permission from you, the client.
• We agree to use the video-conferencing platform selected for our virtual sessions, and I will explain how to use it. Example platforms include doxy.me or Zoom with a business associate agreement obtained.
• You need to use a webcam or smartphone during the session.
• It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
• It is important to use a secure internet connection rather than public/free Wi-Fi.
• It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the counselor in advance by phone.
• We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
• Our safety plan includes a variety of options. You may contact me by phone at (907) 978-4978. If I am unavailable, contact the Careline at 1-877-266-4357, the National Suicide Prevention Lifeline at 1-800-273-8255, call 911 or go to the Fairbanks Memorial Hospital (FMH) ER.
• You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.
• I am not licensed to provide telehealth services outside of the state of Alaska. If you are out of Alaska for any reason, including a vacation or on business, I will be unable to offer telehealth until your return.
• As your counselor, I may determine that due to certain circumstances, Telehealth is no longer appropriate and that we should resume our sessions in-person.