Informed Consent for Telemental Health Services
I hereby consent to engaging in distance counseling with John P. Condron, MS, LCPC (Idaho), CMHC (Utah), MAC, NCC. I understand that distance counseling includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications.
I understand the following with respect to Telemental health services (distance counseling):
- I have the right to be a participant in treatment decisions, to seek a second opinion, to file a complaint without retribution, and to refuse treatment, without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
- The laws that protect the confidentiality of my medical information also apply to distance counseling. As such, I understand that the information disclosed by me in the course of therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards self or an identifiable victim; and defending claims brought by the client against the therapist.
- I understand that John Condron is licensed as a Licensed Clinical Professional Counselor (LCPC-3868) by the State of Idaho, and as a Clinical Mental Health Counselor (CMHC-11743381-6004) by the State of Utah, and that his practice is governed by the state in which I (the client) am located at the time of the session.
- I have the right to be free from being the object of discrimination based on race, religion, gender or other unlawful category while receiving counseling services.
- I understand that there are risks and consequences from distance counseling, including, but not limited to, the possibility, despite reasonable efforts on the part of my counselor, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. These risks are offset by my therapist’s use of a HIPPA-compliant service which is encrypted for video telemental health communications. Further, the contents of my therapist’s computer are encrypted.
- In addition, I understand that telemental health services and care may not yield the same results nor be as effective as face to-face service. I understand that if my counselor believes I would be better served by another form of psychotherapeutic service (e.g. in-person), I will be referred to a counselor in my area who can provide such service.
- My counselor and I will regularly reassess the appropriateness of continuing to deliver services to me using the technologies we have agreed upon today, and modify our plan as needed.
- In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means, including telephone (208-240-0237) or secure email (jcondronLCPC@hushmail.com). I understand that SMS text messaging (e.g., through my cellular provider) and nonencrypted email are not secure and should not be used to convey protected health information.
- It is my responsibility to maintain privacy on the client end of communication. This includes not recording telemental health consultations without discussing the risks with my counselor.
- I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my counselor, my condition may not improve and in some cases may even get worse. I understand that I may benefit from distance counseling, but that results cannot be guaranteed or assured.
- I acknowledge, however, that if I am facing or if I think I may be facing an emergency situation that could result in harm to me or to another person; I am not to seek a telemental consultation. Instead, I agree to seek care immediately through my own local health care counselor, physician or at the nearest hospital emergency department or by calling 911.
To obtain a printable version of the Consent for Telemental Health Services, please click this link: Informed Consent for TMH Services
Print out the form, discuss it with me, sign and return to jcondronLCPC@hushmail.com using secure email, or fax to (208) 233-0835. If you do not have access to a secure email account, you can obtain a free account through Hushmail.