Telehealth Consent Form

The clinicians at Downtown Mind Wellness may offer to meet you via video or telephone rather than in-person. Teletherapy/telemedicine/telehealth allows us to provide services with convenience, accessibility, and effectiveness. However, State of California regulations require us to review and acknowledge with you the following potential risks, issues, limitations, and criteria in order to engage in telehealth services:

1. You confirm that you are physically located within the State of California when receiving telehealth services from the clinicians at Downtown Mind Wellness. We may provide services if you are temporarily located out-of-State, but this must be discussed with your treating provider prior to meeting.
2. Communicating via telephone or video creates unique risks to confidentiality. While we take all reasonable measures to ensure your confidentiality is protected, we cannot guarantee that unauthorized third parties may attempt or succeed to acquire your personal information.
3. A disruption in services may occur due to technological failure or error.
4. Your health insurance benefits and coverage may be different than for in-person sessions. Please be aware; your health insurance may not cover telehealth services.
5. While receiving telehealth services from our clinicians, you are responsible for creating and securing a safe and confidential physical space. If your provider determines that you are located in a physically inappropriate space for conducting confidential services, the session may be terminated at any time.
6. You take full responsibility for the security of your communication device, computer, telephone, or iPad.
7. Whether you qualify as an appropriate candidate to receive telehealth services is determined by both parties, you and the provider. While your provider takes into account patient requests and preferences, the provider may choose not to engage in telehealth services related to your particular diagnosis, history, and possible risk factors.
8. You understand that telehealth sessions may not be as complete, comprehensive, and as effective as face-to-face sessions. Additionally, your provider may not be able to respond as rapidly via telehealth in case of an emergency.
9. Telehealth services are a new and burgeoning mode of rendering mental health services, and all risks, variations, and possible limitations have not been fully examined and explored at this time. You and your provider agree to discuss any possible concerns or questions related to telehealth if any issues arise.
10. Your provider may determine that due to certain circumstances, telehealth is no longer appropriate, and we should resume our sessions in‑person.
11. We recommend you use a secure internet connection rather than public/free Wi‑Fi.
12. You and your provider agree to develop a safety plan in the event of a crisis situation.

By typing your full name below, you agree that you understand all items listed above and agree to participate in telehealth services: