Introduction
This document provides information about Telehealth Services offered by Elle S. Avery Med LPC and seeks your informed consent to participate in mental health services delivered remotely. Please read this form carefully and ask any questions you may have. Your signature indicates that you have read, understood, and agree to the terms outlined below.
What is Telehealth?
Telehealth refers to the provision of healthcare services through telecommunication technologies, such as secure video conferencing, phone calls, or other electronic means. It allows you to receive mental health services from a remote location, such as your home.
Benefits of Telehealth
• Convenience: Access to services from your preferred location, reducing travel time and costs.
• Accessibility: Increased access to mental health care for individuals in rural areas, those with mobility issues, or those with busy schedules.
Risks of Telehealth
While Telehealth offers many benefits, there are also potential risks to consider:
1. Technological Issues: Technical problems (e.g., internet connection failure, audio/video disruptions) may interrupt sessions. In such cases, we will attempt to reconnect. If reconnection is not possible, the session may need to be rescheduled or continued via phone.
2. Privacy and Security: While we use secure, HIPAA-compliant platforms, there is always a minimal risk of security breaches or unauthorized access to electronic communications. We will take all reasonable precautions to protect your privacy.
3. Confidentiality in Your Environment: You are responsible for ensuring the privacy of your location during Telehealth sessions. Choose a private, quiet space where you will not be interrupted or overheard.
4. Emergency Situations: In a mental health crisis or emergency, Telehealth may not be appropriate. We will discuss an emergency plan, including local resources and how to contact emergency services (e.g., 911).
5. Scope of Practice Limitations: Please be aware that sessions are conducted strictly on a virtual basis. In-person sessions are not provided.
6. Jurisdictional Limitations: My license to practice is in Pennsylvania. If you are located outside of Pennsylvania , I will not be able to provide services to you due to state licensing laws. You are responsible for informing me of your physical location at the start of each session.
Confidentiality and Privacy
All information shared during Telehealth sessions will be kept confidential in accordance with professional ethical guidelines and state and federal laws (including HIPAA). Exceptions to confidentiality include:
• If there is a reasonable suspicion of child abuse or elder/dependent adult abuse.
• If you pose an imminent danger to yourself or others.
• If ordered by a court of law.
• With your written consent to share information with specific individuals or entities.
Emergency Procedures
In case of a mental health emergency during a Telehealth session, or if you are experiencing a crisis outside of a scheduled session:
• Immediately call 911 or go to the nearest emergency room.
• Contact your local crisis hotline:
Lehigh County Crisis Intervention - licensed telephone and mobile crisis services that provide mental health assessments to all age groups regardless of income or insurance. Crisis Intervention operates 24-hour/7 days a week.610-782-3127.
• You may also contact me at 610.435.9949 during business hours, but understand that I may not be immediately available.
We will develop a safety plan together that includes local emergency contacts and resources.
Technology Requirements and Responsibilities
• You are responsible for having a reliable internet connection and a device (computer, tablet, or smartphone) with a camera and microphone.
• Please ensure your device is charged and you are in a quiet, private location free from distractions.
• We will use the platform, SimplePractice for our sessions. You may need to download or access this platform prior to our first session.
• I will not record sessions without explicit written consent from clients.
Fees and Payment
• My standard fee for Telehealth sessions is $180 per session length, e.g., 50-minute session. You will be charged the day of your session.
• Prior to the start of therapy, you must fill out and return our credit card authorization form. This form allows us to charge you card directly on the day of your session. The Simple Practice billing software only provides us with access to the last four digits of your credit card number. There is no risk to you regarding their inappropriate use. We accept (e.g., credit cards, debit cards, FSA and HSA cards). You will see the session charge on your monthly bank statement. It will appear as [ELLE AVERY ALLENTOWN].
Cancellation Policy
We kindly request that you cancel or reschedule appointments 24 hours in advance. You will be responsible for a $75 fee if your cancellation is less than 24 hours.
You are expected to show up for therapy at the time scheduled. Therapist will wait 15 minutes. If you do not Log on within that time your appointment will be considered a NO SHOW and you will be charged $75.
Client Rights
You have the right to:
• Ask questions about Telehealth services and this consent form.
• Decline Telehealth services at any time.
• Receive a copy of this consent form.
• Discontinue therapy at any time.
My Responsibilities
I will:
• Ensure the security and privacy of the Telehealth platform used.
• Maintain confidentiality as outlined above.
• Provide appropriate care within my scope of practice.4 of 4
• Refer you to in-person services or other professionals if Telehealth is deemed inappropriate for your needs.
• Be available for emergencies as per our agreed-upon emergency plan.
Consent to Telehealth Services
By signing below, I acknowledge that:
• I have read and understood the information provided in this Informed Consent for Telehealth Mental Health Services form.
• I have had the opportunity to ask questions and have received satisfactory answers.
• I understand the benefits and risks associated with Telehealth services.
• I consent to participate in Telehealth mental health services with Elle S Avery Med LPC.
• I understand my responsibilities regarding technology, privacy during sessions, and emergency procedures.
• I understand the fees and payment policies.