PFHL Consent for Online/Virtual Mental Health Treatment
The following policies will help you understand our processes and procedures. Please agree to all the following to give consent to online/virtual treatment.  Please AGREE to each section and SIGN and DATE at the end.
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Email *
(First and Last) Name of Patient: *
Date of Birth of Patient:   *
(First and Last) Name of Person Completing This Form: *
Relationship of Person Completing This Form to Patient: *
Identify Verification - All patients will have to verify their age and identity by showing their drivers license or other verifiable governmental identification. *
Technology - Providers for Healthy Living's online providers will use HIPPA compliant video services. *
Technology - The patient is responsible for securing his or her own computer hardware, internet access points, and password security. *
Technology - Providers for Healthy Living is not liable for confidentiality breaches when they are caused by patient error. *
Technology - Providers for Healthy Living is not responsible for their patient’s equipment failure, e.g. camera, and/or internet service. *
Technology - Providers for Healthy Living is not responsible for lapses in confidentiality that are in direct response to the patient's actions. *
Disconnection Problems - If video services are not available due to an unplanned equipment or service malfunction, sessions will occur via telephone. *
Recordings Are Prohibited - Patients are not allowed to make an audio or video recording of any portion of the session. *
Risk of Harm - Online mental health treatment is not a crisis-based clinical service. *
Risk of Harm - Online mental health treatment may not be appropriate for patients with active suicidal or homicidal thoughts or patients who are experiencing acute mental health problems, such as manic or psychotic symptoms. *
Risk of Harm - It is the responsibility of the patient to inform their Providers for Healthy Living clinician if they are at risk of harm to self or others. *
Risk of Harm - At intake, a patient who reports being at risk of harm to self or others will not be offered online mental health services from Providers for Healthy Living. *
Risk of Harm - If through the intake evaluation or subsequent sessions, a patient is deemed to be at risk of harm to self or to others, Providers for Healthy Living will terminate the sessions, while providing alternative treatment options. *
Risk of Harm - If a patient who was not formerly at risk should become at risk of such harm to self or others, they must immediately report it to their Providers for Healthy Living provider.  In such cases, a patient may be referred to a traditional program or provider. *
Confidentiality Restrictions - The laws that protect the confidentiality of any medical information also apply to online mental health treatment. *
Confidentiality Restrictions - Information about the patient will only be released with his or her express written permission, with the exceptions of the following cases:  (1) if the provider determines risk of self-harm, (2) if the provider determines risk of harm to others, (3) if the provider is informed about or suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult, or (4) if the provider believes that someone’s mental condition leaves the person gravely disabled. *
Records - The provider will maintain records of online treatment and/or consultation services. *
Records - All clinical records will be maintained as required by applicable legal and ethical standards according to the various professional licensing boards, i.e. American Counseling Association, National Association for Social Workers, American Medical Association, American Psychological Association, etc. *
Payments - Payment is expected at the time of service for all online visits.  Some insurance companies allow for online mental health treatment.  Some don't.  If a patient's insurance company denies the visit for online treatment, he or she will be responsible for the full cost of the visit ($80 for therapy with a counselor or therapist, $100 for therapy with a psychologist, $155 for medication management or therapy with a medical provider, $150 for an intake with a therapist, and $250 for an intake with a medical provider). *
No Shows or Late Cancellations - A fee of $100 will be charged to patients who do not show for their scheduled appointment for therapy and $150 will be charged to patients who do not show for their scheduled appointment for medication management. *
No Shows or Late Cancellations - No show fees must be paid before the patient receives his or her next online or office session with a Providers for Healthy Living provider. *
Patients have the right to refuse consent or withdraw consent for treatment at any time by informing any staff member. *
CLIENT SIGNATURE - By typing your name below, you certify that you understand the risks and limitations to online mental health treatment.  (Please type the full legal name of the person completing this form.  By doing so, you agree that your typed signature has the same validity and meaning as your handwritten signature.) *
Date Signed: *
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