Consent for Telehealth Services

Telehealth involves the delivery of behavioral health services using interactive audio, video, or data communications. I understand that my provider is located in South Carolina and is licensed to practice within this jurisdiction, as well as in the state of Ohio. I agree to verify my physical location at the start of every session to ensure compliance with state licensing board regulations.

To maintain the confidentiality and effectiveness of treatment, I agree to the following:

• Secure Environment: I will participate in sessions from a private, quiet location where I cannot be overheard by others.
• Technology: I will use a secure, high-speed internet connection (when available) and a private device (not a public or work-shared computer).
• Prohibitions: I understand that recording sessions (audio or video) is strictly prohibited without express written mutual consent from both the client and the provider.
• Safety: I will not engage in counseling while operating a moving vehicle.

While telehealth offers increased access to care and convenience, I recognize there are unique risks:

• Technical Failures: Interactions may be interrupted or distorted by technical glitches or internet outages.
• Privacy Limits: Despite the use of encrypted, HIPAA-compliant platforms, there is a theoretical risk of unauthorized access to electronic transmissions.
• Clinical Suitability: Telehealth may not be appropriate for all clinical situations. If my therapist determines that my needs require in-person care or a higher level of support, I agree to follow their referral recommendations.

Because we are not in the same physical location, a safety plan is mandatory. In the event of a mental health crisis or technical disconnection during a crisis:

• I have provided the name and contact information of an Emergency Contact located near me. I agree to keep this contact information updated and inform my clinician of any changes.
• My provider has my current physical address on file for the purpose of contacting local emergency services (911) if a welfare check is deemed necessary.

If we are disconnected during a session, the "Backup Plan" will be:

1. Wait: We will both attempt to reconnect via the video platform for 2 minutes.
2. Phone: If video fails, the therapist will call me at the phone number I have provided in my profile.

I acknowledge that Mental Wellness and Clinical Counseling Services, LLC will not file insurance claims on my behalf.  As such, I understand that I am responsible for confirming the behavioral health Out-of-Network maximums with my insurance company before scheduling my initial appointment. I understand that full payment is due at time of services, and I can request a monthly superbill from my therapist in order to seek some reimbursement from my insurance company. 

I have read and understood the information provided above. I recognize that I have the right to withhold or withdraw my consent for telehealth at any time without affecting my right to future care or treatment.

[Adapted from Blueprint.com forms. Information can be sent electronically via Blueprint.com for clients who schedule an appointment]