Consent to Telehealth Treatment:
By electing to participating in the telehealth treatment services, I agree that I have read and understand the information below regarding telehealth services. I acknowledge I have the opportunity to discuss telehealth consent information with my therapist to have any questions answered to my satisfaction. I also acknowledge that I can choose not to participate in telehealth services or to discontinue telehealth services at any time.
Telehealth (online counseling) includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. Telehealth involves the use of electronic communications to enable health care providers at different locations to deliver care and share individual client information for the purpose of improving client care. The information you provide may be used for diagnosis, therapy, follow-up and/or client education, and may include any combination of the following: (1) health records and assessment results; (2) phone conversations; (3) live two-way audio and video; (4) interactive audio and messaging; and (5) sound and video files. Clients will need access to, and familiarity with, the appropriate technology in order to participate in the service provided
The benefits of the use of telehealth instead of in-person services include increased flexibility of access to care – appointments for telehealth services may be available sooner than in-person appointments, and may also reduce the travel needed to obtain certain types of services.
I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of disorders, there is no guarantee that all treatment of all clients will be effective. Thus I understand that while I may expect the anticipated benefits from the use of telehealth in my care, results cannot be guaranteed or assured.
I understand that there are risks and consequences associated with telehealth including, but not limited to the possibility, despite reasonable efforts on the part of my counselor/therapist/clinical intern, that the transmission of my medical information could be disrupted or distorted by technical failures. In addition, I understand that telehealth-based services and care may not be as complete as face-to-face services. I also understand that if my counselor/therapist/clinical intern believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services). The electronic communication systems we use will incorporate software security protocols to protect the confidentiality of client identification and data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. However, these services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.
Client Rights and Responsibilities
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed to other entities without my consent. The terms of confidentiality remain the same as described in the CSCT informed consent document.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth at any time.
3. I understand that it is my duty to inform my ophthalmologist of electronic interactions regarding my care that I may have with other healthcare providers.
4. I have the right to submit a grievance if I feel that my rights as a client have been violated, under the same policy and procedure applicable to in-person services.
5. I understand that I will be responsible for payment in full for receiving telehealth services per the CSCT consent to bill document.
6. I understand that when BVEC mental health staff provide telehealth services, no one other than the client and/or parents/guardians can be present during the session. Only the client may be present for group treatment sessions to protect the confidentiality of other clients.
7. I understand that neither the BVEC staff, clients or guardians are permitted to record any portion of treatment.
8. I understand that BVEC may not provide telehealth services to me if I am outside of the State of Montana.
9. I understand that telehealth treatment is not appropriate under the influence of alcohol or drugs.
10. I understand some situations including emergencies and crises are inappropriate for telehealth psychotherapy services. If I am in a mental health crisis, agree to contact the BVEC afterhours crisis phoneline, to immediately call 911 or go to the nearest hospital according to the severity of the emergency. I understand an emergency situation may include thoughts about hurting or harming myself, harming others or having uncontrolled psychotic symptoms. The BVEC has procedures in place to ensure my safety in an emergency or urgent situation that arises during the telehealth session. While my therapist may utilize means multiple means of communication (apps, email, text), these methods of communication are not intended for managing crisis or emergency situations.
Consent to Telehealth Treatment: