Online Counseling Consent Form
Additional consent form required to conduct online counseling
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Moscow Counseling LLC | 828 S. Washington St., Suite C | Moscow, ID 83843
Today's Date *
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Client's First Name *
Client's Last Name *
Phone Number *
Name of Emergency Contact (Must be someone who can physically come to your aid) *
Relation of Emergency Contact *
Emergency Contact Phone Number *
Informed Consent for Online Counseling
TOOLS: You will need access to the technological tools and services to participate in Online Counseling such as a computer or smartphone with a webcam and high-speed internet. If you do not have access to such, we will conduct your Online Counseling session via a phone call. By providing your phone number, you are providing permission to contact you via phone should technical issues arise.

RISKS: Online Counseling has both benefits and risks. Some of these risks include: (a) Internet connections and cloud services could cease working or become too unstable to use, (b) Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out, and (c) Your counselor does NOT have the ability to directly intervene in crises or emergencies.

SAFETY: You are required to provide Moscow Counseling LLC contact numbers for mental health crises and medical emergencies. By providing the name and phone number of an emergency contact, you are also providing permission for your Counselor to communicate with these contacts about your care during emergencies. If you are in immediate crisis, you will need to call 911 or report to the nearest emergency room. If your counselor has reason to suspect that you can not or will not contact emergency services or report to an emergency room, your counselor will call 911 on your behalf.

PRIVACY: Moscow Counseling LLC employs software and hardware tools that adhere to security best practices and applicable legal standards which are HIPAA Compliant. However, you also have a role to play in maintaining your security. You will be responsible for creating an appropriate, safe, and private/confidential space for your Online Counseling sessions. You will need a space that is free of other people and this space should also be difficult for people outside the space to see or hear your interactions with your counselor during the Online Counseling session.

APPROPRIATENESS: Although it is well validated by research, Online Counseling is not a good fit for every person. Together, we will continuously assess if Online Counseling is appropriate for you. Please let your counselor know if you find Online Counseling too difficult to use, if it distracts from the services being provided, if it causes trouble focusing on your services, or if there are any other reasons why you find Online Counseling inappropriate for you. We will develop alternative means for service.

Agreement to Consent for Online Counseling *
Required
Client/Legal Guardian Electronic Signature (Type Full Legal Name) *
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