By checking the "I have read and acknowledge the terms of teletherapy" below, I understand, acknowledge and agree that I am signing this Consent electronically, that I have reviewed, understand and accept the risks and benefits of telehealth services as described below, and that I wish to receive those services.
   If I am agreeing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services.
1. By acknowledging below, I agree to receive teletherapy services. Teletherapy involves the delivery of counseling services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my CCG Counselor and I will be able to see and/or speak with each other from remote locations.
2. I understand that if I am seeing my CCG counselor in-person on a regular basis, I may be asked to transition to teletherapy if (i) I am experiencing symptoms of illness and want to continue to have counseling; (ii) my CCG counselor is experiencing symptoms of illness but is willing to continue counseling remotely; and/or (iii) I need to stay home to care for family members due to illness and/or care facility closures. I also understand that though I have been offered this transition, I have the right to refuse teletherapy, and that if I do, I will need to reschedule my appointment for another day.
3. I understand and agree to the following about teletherapy:
• I will not be in the same location or room as my CCG counselor.
• My CCG Counselor must be licensed/certified in the state in which I am receiving services. I will report my location accurately at the beginning of each session.
• Potential benefits of teletherapy (which are not guaranteed or assured) include: (i) access to counseling services if I am unable to travel to my CCG counselor’s office; (ii) during the COVID-19 pandemic, reduced exposure to patients, staff and other individuals at a physical location; (iii) less need for the counselor/patient to wear mask, therefore allowing better communication.
• Potential negatives of teletherapy include: (i) Less opportunity for my CCG counselor to read body language in communication; (ii) restriction of options for engagement with youth through play therapy and games; (iii) restrictions and/or limitations in insurance coverage.
• I may discuss these pros and cons with my CCG counselor. I understand that I have the right to withdraw this consent for teletherapy services or end the teletherapy session at any time.
• I understand that the level of care provided by my CCG counselor is the same level of care that is available to me through an in-person counseling visit. However, if my CCG counselor believes I would be better served by face-to-face services, I will have the option of transitioning to face-to-face counseling and referred to a counselor who offers it within CCG if necessary.
• I understand that there are unique risks specific to teletherapy services including, but not limited to, the possibility of disruption, distortion or unauthorized access during transmission of Protected Health Information (PHI) or Personally Identifiable Information (PII) due to internet/electronic/technical failures beyond the control of CCG. The Zoom video conferencing platform used by CCG is HIPAA compliant for privacy/security, and I will visit it for instructions prior to initiating teletherapy. I understand that I am solely responsible for the privacy and confidentiality in my surrounding environment while engaged in teletherapy and will exercise appropriate privacy measures.