Informed Consent for Telehealth Services

Informed Consent for Telehealth Services

2 Main Street
Florence, MA 01062-3500
(413) 584-0265 ∙ Fax (413) 584-2031

  • There are potential benefits and risks of videoconferencing (e.g. limits to client’s confidentiality) that differ from in-person sessions.
  • Confidentiality still applies for telehealth services, and nobody will record the session without the permission from the others person(s).
  • We agree to use the video-conferencing platform selected for our virtual sessions, and the Learning Solution’s staff member will explain how to use it.
  • You need to use a webcam or smartphone during the session.
  • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
  • It is important to use a secure internet connection rather than public/free Wi-Fi.
  • It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the Learning Solution’s staff member in advance by phone or email.
  • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
  • We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation.
  • If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telehealth sessions.
  • You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.
  • As your clinician, I may determine that due to certain circumstances, telehealth is no longer appropriate and that we should resume our sessions in-person


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Document name: Informed Consent for Telehealth Services
lock iconUnique Document ID: 43a4419eb36a062f1fa65f82a70688b339c3038c
Timestamp Audit
August 13, 2020 8:16 am EDTInformed Consent for Telehealth Services Uploaded by Leslie Roberts - IP
October 5, 2020 12:48 pm EDT Document owner has handed over this document to 2020-10-05 12:48:55 -