I hereby authorize Ray of Hope Child Therapy Services Inc to use HIPPA compliant and secure telemedicine technology for our therapy sessions.

I understand that there is a possibility that our technology may fail during a teletherapy session, and that there may be an interruption or need to reschedule. I authorize therapist to use my address info and emergency contact as part of a safety plan, should an emergency arise.

I understand that during the therapy process, my therapist may decide that teletherapy is not the most appropriate type of therapy for my needs, and may help connect me to other mental health services.

I understand that my therapist is only licensed to practice in the state of California. Tura Johnson, LMFT is licensed to practice in the state of California, Illinois, North Carolina, South Carolina and Florida. I understand that if I move or travel out of the state, I will need to obtain other mental health services.

I understand that I may revoke this authorization at any time by giving my written notice. I may specify the date, event, or condition on which this content expires. If none is stated, and if no prior notice of revocation is received, this consent will expire one year after the date initiated.

CONSENT TO USE THE TELEHEALTH BY GOOGLE MEET SERVICE

Telehealth by Google Meet is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use, and there are no passwords required to log in. By signing this document, I acknowledge:

Telehealth by Google Meet is NOT an Emergency Service, and in the event of an emergency, I will use a phone to call 911.
Though my provider and I may be indirect, virtual contact through the Telehealth Service, neither Google Meet nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Telehealth by Google Meet Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice, or care.
I do not assume that my provider has access to any or all of the technical information in the Telehealth by Google Meet 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 Google Meet Service.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents, including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.