Associated Therapists, Inc.
Consent For Teletherapy Services

Teletherapy is a form of psychological service provided via internet technology, which can include consultation, treatment, transfer of medical data, emails, telephone conversations and/or education using interactive audio, video, or data communications. It involves the communication of my medical/mental health information, both orally and/or visually.

Teletherapy has the same purpose or intention as psychotherapy or psychological treatment sessions that are conducted in person. However, due to the nature of the technology used, teletherapy may be experienced somewhat differently than face-to-face treatment sessions.

Potential Benefits:

  1. Increased accessibility to psychological care

  2. Convenience and flexibility

Potential Risks/Limitations:

As with any healthcare service, there may be potential risks associated with the use of teletherapy. 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 clinical decision making by the provider.

  2. Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment.

  3. Security protocols could fail, causing a breach of privacy of personal medical information.

  4. There is a risk of being overheard by anyone near you if you do not ensure your privacy during the teletherapy session.

  5. Teletherapy does not provide emergency services. If you are experiencing an emergency situation, such as an imminent threat to yourself or others, you understand that you can call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, you can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24-hour hotline support. Clients who are actively at risk of harm to themselves or others are not suitable for teletherapy services.

  6. Teletherapy, as in-office therapy, is by appointment only.

My Rights and Responsibilities:

  1. I am a resident of California

  2. I will not record any teletherapy sessions without prior written consent from my provider.

  3. I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session. It is the responsibility of the psychological treatment provider to do the same on their end.

  4. I will inform my provider if any other person can hear or see any part of our session before the session begins. My provider will ensure that no other person can see or hear any part of the session, but if there is an unforeseen circumstance, my provider will inform me if any other person can hear or see any part of our session.

  5. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are described in the intake document “Office Policies and General Information Agreement to Provide Mental Health Services” that I signed upon initiation of therapy services.

Consent to use Teletherapy

I have read and understood the information provided above regarding teletherapy, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of teletherapy during the course of my diagnosis and treatment.

Signature of Client (or personal representative): *
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