Welcome to therapy. This document (this “Consent Form”) contains important information about the use of Google Meet services to assist in the in-session interaction between you, the client, and me, the therapist at Gonzalez Family Therapy. 

In an attempt to expedite the verification process, Gonzalez Family Therapy asks that you, the client, read and sign this Consent Form electronically before receiving therapy. . 

The electronic consent process requires all documents to be sent through your personal email account specified in this consent form.

By selecting the "I accept" button below and inserting your name, initials, email and date at the bottom of this Consent Form, you acknowledge and agree that you are signing this Consent Form electronically and agreeing to its terms and conditions. You acknowledge and agree that your electronic signature is the legal equivalent of your manual/handwritten signature on this Consent Form. By selecting "I accept" using any device, means or action, you consent to the legally binding terms and conditions of this Consent Form. You further acknowledge and agree that inserting your name, initials, email address and date at the bottom of this Consent Form (hereafter referred to as your "E-Signature") is as valid and legally enforceable as if you manually signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Gonzalez Family Therapy. You acknowledge and agree that you are the client authorized to enter into this Consent Form.

By selecting the “I accept” button below, you specifically agree to receive, obtain, and/or submit any and all Gonzalez Family Therapy documents and information electronically. These documents and information will be collectively known as Electronic Medical Records (“EMR”), and may include information about your reasons for seeking therapy, a description of the ways in which your problems impact your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that Gonzalez Family Therapy receives from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone. You acknowledge and agree that you are able to use your personal email account specified below and are able to retain electronic communications by printing and/or downloading and saving this Consent Form and any other agreements, electronic communications, documents, or records that are signed using your E-Signature. You accept such electronic communications provided via email as reasonable and proper notice for the purpose of fulfilling any and all rules and regulations, and agree that such electronic communications fully satisfy any requirement that communications be provided to you in writing or in a form that you may keep. We recommend that you print a copy of this Consent Form for future reference. You acknowledge and agree that you will keep or maintain all electronic communications records, including this Consent Form, and print or make an electronic copy of all such records.

You have the right to withdraw and revoke your consent to submit communications via your personal email at any time. By selecting “I accept” below, you acknowledge and agree that you are aware that any such revocation may delay the process of reviewing your medical record. If you wish to withdraw and revoke your consent, you must contact Gonzalez Family Therapy, office manager, therapists, or other staff.

You are responsible for installation, maintenance, and operation of your computer, browser and software. Gonzalez Family Therapy is not responsible for errors or failures due to any malfunction of your computer, browser or software. Gonzalez Family Therapy is also not responsible for computer viruses or related problems associated with use of an online system. Your E-Signature indicates that you have access to the Internet, an email account capable of receiving communication from Gonzalez Family Therapy and appropriate software to review any and all electronic communications (e.g., a .pdf reader).

You may not sign/e-sign a document or transaction at Gonzalez Family Therapy including this Consent Form, on behalf of another individual, unless you have been granted specific, written and legal authority to do so by that individual or by a court of competent jurisdiction.

You agree to report any suspected fraudulent activities related to electronic signatures immediately to the supervisors, therapists, or staff at Gonzalez Family Therapy. 

You acknowledge and agree that if you falsify an electronic signature, you may be subject to appropriate civil or criminal penalties or proceedings under applicable federal and state laws.

Because of the nature of federal, state, and institutional guidelines affecting mental health and relationship care services, the information contained in this Consent Form is subject to change. You agree to indemnify, hold harmless and release Gonzalez Family Therapy and its trustees, agents and employees from and against any and all losses, damages, claims, demands and actions arising from or related to any changes made to this Consent Form.

Telehealth services allow for remote treatment and are ideal for clients who are in Tennessee but unable to meet with their therapist on location in our Nashville office. Our telehealth services allow us to provide innovative, high quality care for our clients whenever in-person therapy isn’t a good fit. 

Another benefit of telehealth services is that they allow us to serve all Tennessee residents, not just those who live in an around Nashville. 

Meet, a video meeting experience from Hangouts, allows for Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant use between health professionals and their clients. This is important because the things we will talk about while using Meet are likely to be personal and taking appropriate steps to help keep our conversations confidential is required by law and is considered best practice in the mental health field. All video and audio streams in Meet are encrypted and Meet users can join securely even when they're out of my office. This means that you and I will be able to communicate with the added confidence that the content of our discussion is secured according to industry standards. 

In order to use Meet, you will have to download the Meet application from the Apple App Store or Google Play:

https://itunes.apple.com/us/app/hangouts-meet/id1013231476?mt=8

https://play.google.com/store/apps/details?id=com.google.android.apps.meetings&hl=en_US

Even though Meet is an encrypted service and Google has sought and received security certifications such as ISO 27001 certification and SOC 2 and SOC 3 Type II audits, I do ask you to please remember that there is always a risk of a breach of confidentiality whenever you share your personal information. I also want you to be aware that your computer and other electronic devices may not be secured according to health industry standards.

In order to decrease the chances that the confidentiality of your personal information is compromised, I highly suggest you consider doing the following:

1. Only use Meet when you have taken steps to decrease the likelihood that you can be overheard. These steps include:

a. Making sure you are alone in a room when using Meet.

b. Placing a sound dampening device such as a white noise machine outside the room where you are using Meet.

2. Enable two-step verification when logging into your email accounts. This security measure makes it harder for someone to breach your email and gain access to your computer or other electronic devices. 

3. Limit access by being careful who you allow to use, look after, or borrow your computer or other electronic devices. 

4. Be sure to log out of Meet after use.

5. Encrypt your computer and other electronic devices

a. To encrypt Apple-made mobile devices, you need to enable password protection on your iOS device. This can be done via the Touch ID & Passcode section of Settings. iOS mobile devices used to access clients’ PII should not be backed up to cloud storage services. 

b. On Android devices, encryption can be enabled in the Security or Lock Screen area under settings. 

c. To encrypt a Mac computer, enable Apple's FileVault encryption in the Security & Privacy system preferences. If there are multiple user accounts on the Mac, be sure to enable encryption on each one that requires protection. I suggest using a different FileVault password than the one associated with an iTunes or iCloud account; if an unauthorized individual gains access to an iTunes or iCloud password, it cannot be used to decrypt the computer. 

Apple Time Machine backups and any external drives also need to be encrypted. When setting up a backup drive, the Time Machine can by encrypted in the Time Machine system preference by clicking Select Disk, selecting the backup drive, enabling the Encrypt Backup option, and clicking Use Disk. In OS X El Capitan, external drives can be encrypted, including a Time Machine backup drive, by right-clicking or Control-clicking it in the Finder and choosing Encrypt from the contextual menu that appears. In older OS X versions, Disk Utility can be used to encrypt a drive: select the drive in its Sidebar, then choose File > Encrypt or File > Lock, depending on the OS X version. 

d. On a PC, enabling encryption is accomplished by activating Microsoft's BitLocker. The PC will likely need to have a Trusted Protection Module (TPM) on its motherboard, but it's often missing on cheaper PCs and even expensive older PCs. The computer must also be running the Pro, Ultimate, or Enterprise editions of Windows Vista or later. If the PC is BitLocker- compatible, the BitLocker Drive Encryption settings (called Manage BitLocker in Windows 10) can be found in the Security control panel. In some cases, external drives can also be encrypted here. 

If a PC doesn't support BitLocker, a third-party encryption tool like VeraCrypt must be used.

6. Regularly implement software patches and update antivirus software on personal computers. 

7. Avoid the following to reduce the likelihood of malware getting installed on your computer and other electronic devices: 

a. Downloading bundled free software programs. Programs advertised as “free” often come with the cost of downloading malicious software to a computer. 

b. Using file sharing, BitTorrent, and other peer-to-peer sharing services 

c. Connecting removable media (e.g., USB chargers, thumb-drives, etc.) of unknown origin to computers. These devices can contain malware if they were previously connected to an infected computer. 

d. Downloading scareware. Scareware is also known as rogueware and it is usually presented as Internet security software. These programs are advertised in pop-up windows that say things like “Your computer is infected!” 

e. Clicking on unknown links in emails and on websites. These links often masquerade as advertisements and phishing emails that play on the reader’s emotions. These links may say something like “You won’t believe what happened in this video” or “These people need your help!” 

8. Use a secured internet connection when conducting sessions via Google Meet. Publicly available internet connections like those available in coffee shops and airports are often not secured, meaning that others can access and monitor your internet activity, including your telehealth session. 

I, the client, have fully read and agree to the terms outlined in this STATEMENT OF UNDERSTANDING OF THE USE OF GOOGLE MEET SERVICES and give consent for use of Google Meet. I have discussed any questions I had with my therapist or therapist intern and/or Gonzalez Family Therapy staff and I understand the information in this consent. I acknowledge and agree that Gonzalez Family Therapy cannot guarantee the privacy and confidentiality of any communication through Google  Meet, and hereby hold harmless and release Gonzalez Family Therapy and all its trustees, agents and employees from and against any and all losses, damages, claims, demands and actions arising from or related to any breach of privacy or confidentiality in connection therewith. I hereby give my informed consent for the use of Google Hangouts Meet Services for myself and on behalf of any of my minor children who receive therapy services as discussed above.

By inserting my name, initials, and date below, I hereby acknowledge and agree that I have read and understood this Consent Form, am at least 16 years old and fully competent, and have executed the same as my own free will.

(Parents giving consent for the treatment of any of their minor children will put their name not the minor child's name below)

IN THE SPACE BELOW PLEAE WRITE YOUR 

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