Community School Health Center

Informed Consent for Tele-Health Sessions 

Rider As of March 15, 2020

I hereby consent to participate in tele-mental/tele-medical health with Full Service Community Schools as part of my child’s, psychotherapy.  I understand that telemental/tele-medical health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand the following with respect telemental/tele-medical health.

1)  I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled. 

2)I understand that there are risk and consequences associated with telemental/tele-medical health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. In addition, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call me at the number below to discuss since we may have to re-schedule.

3)  I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law. 

4)  I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental/tele-medical health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding). 

5)  I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental/tele-medical health services are not appropriate and a higher level of care is required. 

6.I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency. 

Emergency Protocols 

I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life- threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency. 

In case of an emergency, my information is:

I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction. 

Signature of client/parent/legal guardian: