Teletherapy Consent Form |HOPE Counseling & Consulting Services, Inc.

Teletherapy and Telemedicine Consent Form

(1) "Teletherapy" and "Telemedicine" includes consultation, treatment, emails, telephone conversations, and other medical information using interactive audio, video, or data communications.

(2) Teletherapy and Telemedicine occurs in the state ofNC (USA), and is governed by the laws of that state. In a manner of speaking, I am using this modality to visit my therapist in their NC office, where we meet to do our work.

(3) The laws that protect the confidentiality of my medical information also apply to teletherapy. Unless we explicitly agree otherwise, our teletherapy exchange is confidential. I will not include others in the session or have others in the room unless agreed upon.

(4) I accept that Teletherapy and Telemedicine does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help.

(5) In the event our Teletherapy and Telemedicine is not in my best interests, my therapist will explain that to me and suggest some alternative options better suited to my needs.

(6) I understand there are risks and consequences from Teletherapy and Telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. I am responsible for information security on my computer.

I have read, understand, and agree to the above information.

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Signed by Linda McRae
Signed On: February 15, 2024

Timestamp

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July 13, 2021 5:06 pm EDT

Teletherapy and Telemedicine Consent Form Uploaded by Linda McRae - info@thereishopeinc.com IP 199.30.185.69

November 3, 2021 3:05 pm EDT

Linda McRae - info@thereishopeinc.com added by Linda McRae - info@thereishopeinc.com as a CC'd Recipient Ip: 73.127.40.137

October 6, 2022 4:32 pm EDT

Linda McRae - info@thereishopeinc.com added by Linda McRae - info@thereishopeinc.com as a CC'd Recipient Ip: 49.145.131.130

October 6, 2022 4:36 pm EDT

Linda McRae - info@thereishopeinc.com added by Linda McRae - info@thereishopeinc.com as a CC'd Recipient Ip: 49.145.131.130

October 6, 2022 4:42 pm EDT

Linda McRae - info@thereishopeinc.com added by Linda McRae - info@thereishopeinc.com as a CC'd Recipient Ip: 49.145.131.130

October 6, 2022 4:44 pm EDT

Linda McRae - info@thereishopeinc.com added by Linda McRae - info@thereishopeinc.com as a CC'd Recipient Ip: 49.145.131.130