TELEHEALTH CONSENT FORM
This form explains your rights and responsibilities when receiving mental health services through telehealth at Mental Alive. Telehealth allows you to receive care through secure video or phone sessions from the comfort of your own space.

Please review the information carefully. It includes details about confidentiality, potential risks, benefits, and how telehealth works. At the end of the form, you’ll be asked to confirm your understanding and consent by typing your full name.

If you have any questions before proceeding, please contact us at 561-614-8731
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CONSENT FOR TELEHEALTH CONSULTATION

  1. I understand that my health care provider wishes me to engage in a telehealth consultation.
  2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit since I will not be in the same room as my provider.
  3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
  4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
  5. I had a direct conversation with my provider, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language in which I understand.
CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE
Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
  1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
  2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
  3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
  4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up to date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
  5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
Acknowledgment & Agreement  

By typing my name below, I confirm that I have read, understood, and agree to the terms outlined in this document.  

Please type your full name as your digital signature   *
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