Telepsych Patient Consent Form

Telehealth involves the use of electronic communications to enable providers and other healthcare professionals (‘treatment providers’) at different locations to share individual patient medical information for the purpose of improving patient care. Treatment Providers may include, but are not limited to, psychiatrists, psychologists, nurses, counselors, clinical social workers, and marriage and family therapists.

The information may be used for healthcare delivery, diagnosis, treatment, transfer of medical data, therapy, consultation, follow-up and/or education, and may include the following:

• Patient medical records
• Medical images
• Live, two-day audio & video
• Output data from medical devices and sound & audio files
• Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption

Since this may be different than the type of consultation with which you are familiar, it is important that you understand and agree to the following statements:

EXPECTED BENEFITS:

1. Improved access to medical care by enabling a patient to remain at remote sites while the Treatment Provider obtains test results and consults healthcare practitioners at distant/other sites
2. More efficient medical evaluation and
3. Obtaining the expertise of a distant

POSSIBLE RISKS:

Although rare, there are potential risks associated with the use of telemedicine. These risks include but may not be limited to:

1. Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the Treatment Provider and consultants
2. Delays in medical evaluation and treatment could occur due to technical deficiencies or failures
3. The transmission of patient’s medical information could be interrupted by unauthorized persons
4. A lack of access to complete medical records may result in incomplete diagnosis, adverse drug interactions or allergic reactions or other judgment errors

NECESSITY OF IN-PERSON EVALUATION

If it becomes clear the telemedicine modality is unable to provide all pertinent clinical information during a particular telemedicine encounter, the Treatment Provider must make it known to the patient prior to the conclusion of the live telemedicine encounter regarding the need for the patient to obtain an additional in-person medical evaluation reasonably able to meet the patient’s needs.

BY SIGNING THIS FORM, I UNDERSTAND THE FOLLOWING:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to I understand that the information disclosed by me, during my treatment, is confidential. However, there are both mandatory and permissive exceptions to confidentiality, including but not limited to: information demonstrating a probability of imminent physical injury to myself or others; immediate mental or emotional injury to myself; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine during my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect information obtained during a telemedicine interaction and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical care may be available to me, and that I may ask my Treatment Provider about alternative methods of care to telemedicine.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be in other areas.
6. I understand that it is my duty to inform my Treatment Provider of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that telemedicine-based services and care may not be as complete as face-to­ face services. I also understand that if my Treatment Provider believes I would be better served by another form of service (e.g. face-to-face services), I will be referred to a Treatment Provider who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of treatment, and that despite my efforts and the efforts of my Treatment Provider, my condition may not improve, and in some cases may even get worse.
8. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
9. I understand that in the event of an adverse reaction to treatment, or in the event of an inability to communicate because of a technological or equipment failure, I shall seek follow­ up care or assistance at the recommendation of my Treatment Provider.
10. Risks, benefits, and alternatives to treatment medication were explained and questions were answered. I have been advised to promptly notify the staff should I experience any   unexpected change in clinical condition or mental health. I am aware that we do not offer on- call services and any after-hours emergencies should be directed to the nearest emergency room.
11. Complaints against Treatment Providers, as well as other health care providers, may be reported for investigation to the appropriate licensing board of the state in which patient received the services.

MENTAL HEALTH SERVICES:

The therapeutic relationship is unique in that it is highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me.

THE THERAPEUTIC PROCESS:

You have taken a very positive step by deciding to seek mental health care. The outcome of your treatment depends largely on your willingness to engage in this process and openly discuss your emotions. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and find medication to help manage your condition.

CONFIDENTIALITY:

The session content and all relevant materials to the patient’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such patient-held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts themselves in a way that there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the provider has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a patient is in treatment or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

PATIENT EXPECTATIONS:

• Patients will take medication as prescribed.  Medication can cause serious harm, permanent injury or death if not taken as prescribed or if taken in an overdose.  Medication must be kept in a secure location so that children or teenagers do not have access to it.  To avoid problems of medication interactions, check with the pharmacist or the physician prescribing additional medication. Do not abruptly stop medication without contacting a medical provider. It is the patient’s responsibility to disclose medical history and medications they are taking and notify provider of any changes.
• Being 10 minutes late to an appointment will result in the appointment being canceled.
• Any patient having 3 missed appointments will be discharged from the program. Please give us a call at (844) 414-2072, if you need to reschedule or have any questions/concerns.
• Verbal/written aggression or threats towards staff will result in dismissal.