Spencer Psychology

Consent for Online Counseling - Telehealth Services

I consent to telehealth services (e.g., internet or telephone based therapy) with Spencer Psychology as a venue for my psychotherapy treatment. I understand that telehealth includes the practice of health care delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer of psychotherapy data, and education using interactive audio, video, and/or data communications. I understand that I have the following rights with respect to telehealth:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.

(2) The laws that protect the confidentiality of my psychological/medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, standard mandatory reporting laws are still in effect for child/elder abuse, and disclosures of harm to self or others.  (Please see our website for details at https://spencerpsychology.com/our-policies/privacy-practices-for-phi/)

(3)  I understand that there are risks and consequences from telehealth. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical/psychological information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; the electronic storage of my medical/psychological information could be accessed by unauthorized persons and/or misunderstandings can more easily occur. In addition, I understand that telehealth based services and care may not yield the same results nor be as complete as face-to-face service (though this is not supported in the research). I also understand that if my therapist believes I would be better served by another form of therapeutic service (e.g. face-to-face service), this will be recommended. Finally, I understand that there are potential risks and benefits associated with any form of therapy, and that despite my efforts and the efforts of my therapist, and though unlikely, my condition may not improve and in some cases may even get worse.

(4) I understand that I may expect to receive the anticipated benefit from telehealth, but results cannot be guaranteed or assured. The benefits of telehealth may include, but are not limited to: finding a greater ability to express thoughts and emotions; transportation, childcare and travel difficulties are avoided; and time constraints and lost work hours are minimized.

5) I understand that I have the right to access my medical/psychological information and copies of my records in accordance with Indiana law, that these services may not be covered by insurance and that if there is inten-tional misrepresentation, therapy will be terminated.

Spencer Psychology website

Client Name:  

Electronic Signature of Client/Parent/Guardian: