Please read this form carefully and ask your provider if you have any questions.  Then answer the questions at the bottom of the page.

Overview

1. You will need access to the certain technological services and tools to engage in telemental health-based services with me
2. Telemental health has both benefits and risks, which you and I will be monitoring as you proceed with your work
3. It is possible that receiving services by telemental health will turn out to be inappropriate for you, and that you and I may have to cease work by telemental health
4. You can stop work by telemental health at any time without prejudice
5. You will need to participate in creating an appropriate space for your telemental health sessions
6. You will need to participate in making a plan for managing technology failures, mental health crises, and medical emergencies
7. I follow security best practices and legal standards in order to protect your health care information, but it is important that you also participate in maintaining your own security and privacy

What is Telemental Health?
           
            Telemental Health includes the use of electronic communications, information technology, or other electronic or technological means to provide assessment, diagnosis, intervention, consultation, education and information across distance via technology such as telephone, e-mail, text, and/or videoconferencing.

Benefits and Risks of Telemental Health

Receiving services via telemental health allows you to:
• Receive services at times or in places where the service may not otherwise be available
• Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings
• Receive services when you are unable to travel to my office

Receiving services via telemental health has the following risks:
• Telemental health services can be impacted by technical failures, may introduce risks to your privacy, and may reduce my ability to directly intervene in crises or emergencies.
o Here is a non-exhaustive list of examples:
 Internet connections could cease working or become too unstable to use
 Malicious actors (“hackers”) may have the ability to access your private information that is transmitted or stored in the process of telemental health-based service delivery
 Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out.
 Interruptions may disrupt services at important moments, and I may be unable to reach you quickly or using the most effective tools. I may also be unable to help you in-person.

            There may be additional benefits and risks to telemental health services that arise from the lack of in-person contact or presence, the distance between you and I at the time of service, and the technological tools used to deliver services. We will assess these potential benefits and risks as our relationship progresses.

Assessing Telemental Health’s Fit for You

            Although it is well validated by research, service delivery via telemental health is not a good fit for every person and results cannot be guaranteed or assured. I will continuously assess if working via telemental health is appropriate for your needs. If it is not appropriate, we can either transition to face-to-face counseling (if possible) or I will refer you to a professional/organization who can meet your needs.

            Crisis sessions are generally not appropriate for telehealth. If you are in a crisis or emergency or if you feel unsafe you should call 911 or proceed to the nearest emergency room.  

            You also have a right to stop receiving services by telemental health at any time without prejudice.

Your Telemental Health Environment

            You are responsible for creating a safe and confidential space during sessions. You should use a space that is free of other people. It should also be difficult or impossible for people outside the space to see or hear your interactions with me during the session. I will do the same. If you are unsure of how to do this, please ask me for assistance.

Our Communication Plan

•  I typically provide telemental health services using Google Meet (HIPAA compliant business class video conferencing). You will need access to Internet service and a phone, tablet, or computer that is equipped to handle videoconferencing.  If you have any questions or concerns, please let me know and we can discuss any risks, benefits, and/or specific applications for your care.
•. During our first session, we will develop a plan for backup communications in case of technology failures and a plan for responding to emergencies and mental health crises.
     o If our telemental health session is interrupted, please sign out and back in. If we are unable to continue via video, I will contact you at the phone number you provide. If you want me to call you at a different number, please email me immediately (MelissaCole@yourhappyisyou.com) with that number. Alternatively, you can leave me a voicemail at 856-975-0055.
     o Our work is done during our sessions. Contact between sessions should be limited to making or changing appointments, or billing questions or issues. All messages you exchange with me will become a part of your health record.
     o If requested, with your permission (or in case of emergency) I will coordinate care with one or more of your other providers. I’ll use reasonable care to ensure that those communications are secure, and they safeguard your privacy

Our Safety and Emergency Plan

As a recipient of telemental health services, ensuring your safety during mental health crises, medical emergencies, and sessions that we have is imperative.
•. The designation of an emergency contact enables me to communicate with this person about your care during emergencies only.
•. I will also develop with you a plan for what to do during mental health crises and emergencies, and a plan for how to keep your space safe during sessions.

Your Security and Privacy

            Except where otherwise noted, I employ software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged. As with all things in telemental health, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with me, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that I have supplied for communications.

Recordings

            Please do not record video or audio sessions without my consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. I will not record video or audio sessions.