Online Counseling Consent

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Online Counseling Consent
Location*
Client Name*
The use of online counseling (also called telecommunication, (telemedicine, electronic service delivery) for therapy has been shown to be effective; It involves special considerations.
1. Prior to offering such services, a client must be seen in face-to-face counseling for a diagnosis assessment to assess suitably for online counseling.
2. If a client changes their legal residence to a location outside of Ohio, Churchill will not be able to continue to provide services, at which time an appropriate continuity of care plan will be developed. The exception will be those clients who live in Eastern Pennsylvania and have an established case with Churchill.
3. Emergency: In the event of an emergency, the client will call our office (If after hours, our 24-hour service will answer the call), call 911, or go to their nearest emergency department.
4. If the use of technology does not seem to be working well, the client may continue with face-to-face counseling on Churchill’s premises.
5. It is understood that online counseling is to be used as an alternative when it is not possible to obtain services on Churchill’s premises. Examples include mental (e.g., severe agoraphobia) or physical illness, severe weather, power outages, etc.
6. Documentation of online counseling sessions will be maintained in the same manner as face-to-face sessions.
7. If the online session is not covered by the client’s Insurance, the client will be responsible for payment of the online session.
8. Churchill Counseling cannot guarantee that online sessions will remain confidential due to possible risks of hacking, using a public access computer or shared network, using auto-filler names and/or passwords, Should Churchill Counseling become aware of a breach of security, the client will be notified as soon as possible.
9. I understand that CCS offers online counseling via doxy.me and TherapyNotes (HIPAA protected).
10. Online sessions will not be video or audio recorded.
11. If a session is interrupted due to power or technology failure, attempts will be made to reconnect, either through small or telephone.
12. I choose to use the following methods of electronic service delivery
Check All that Apply*
- Phone
- Doxy.me
- Therapy Notes
- Other
Other Services
Client Signature*
Date*
MM slash DD slash YYYY
Parent/Guardian Signature
Date
MM slash DD slash YYYY