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: November 3, 2021


Signature Certificate
Document name: Teletherapy and Telemedicine Consent Form
lock iconUnique Document ID: 3b3bd69b3f5d906874b248b22a87c0736005e949
Timestamp Audit
July 13, 2021 5:06 pm GMTTeletherapy and Telemedicine Consent Form Uploaded by Linda McRae - info@thereishopeinc.com IP 73.127.40.137
November 3, 2021 3:05 pm GMTLinda McRae - info@thereishopeinc.com added by Linda McRae - info@thereishopeinc.com as a CC'd Recipient Ip: 73.127.40.137