Footsteps Counseling Telemedicine Informed Consent Form
I _________________________(patient’s name) hereby consent to engaging in telemedicine as part of my psychotherapy. I
understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data,and education using interactive audio, video, or data communications.
Because of recent advances in communication technology, the field of tele-therapy has evolved. It has allowed individuals who may nothave local access to a mental health professional to use electronic means to receive services. Because it is relatively new, there is nota lot of research indicating that it is an effective means of receiving therapy. An important part of therapy is sitting face to face with anindividual, where non-verbal communication (body signals) are readily available to both therapist and client. What is important here isthat you are aware that tele-therapy may or may not be as effective as in-person therapy and therefore we must pay close attention to
your progress and periodically evaluate the effectiveness of this form of therapy.
The counseling services you are receiving is from a Footsteps Counseling office and therefore are bound by the laws of the State ofVirginia. These laws are primarily related to confidentiality as outlined in this form and on the treatment consent form.
I understand that I have the following rights with respect to telemedicine:(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss
or withdrawal of any program benefits to which I would otherwise be entitled.
(2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that theinformation disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory andpermissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressedthreats of violence towards an ascertainable victim; 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 toresearchers or other entities shall not occur without my written consent.
(3) I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite
reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted bytechnical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronicstorage of my medical information could be accessed by unauthorized persons.
In addition, I understand that telemedicine based services and care may not be as complete as face-to-face services. I also understandthat if my psychotherapist believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I
will be referred to a psychotherapist who can provide such services in my area or come in to a Footsteps office. Finally, I understandthat there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of mypsychotherapist, my condition may not be improve, and in some cases may even get worse.
(4) I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.
(5) I understand that I have a right to access my medical information and copies of medical records in accordance with Virginia law.
(6) This telehealth consent is an ADDITIONAL consent to your treatment consent (not a replacement). All Footsteps Counselingpolicies apply to telehealth services.
I have read and understand the information provided above. I have discussed it with my psychotherapist, and all of my questions havebeen answered to my satisfaction.
Signature of patient/parent/guardian. If signed by other than patient indicate relationship______________________________________________
Print Name______________________________________________
Signature______________
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