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Telemental Health Informed Consent

Telemental Health Informed Consent

200 Little Falls St., #306, Falls Church, VA 22046


hereby consent to participate in tele-mental health with

that tele-mental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

We are offering HIPAA compliant platforms such as Google Meet and doxy.me . If you decide to choose any other such as messenger, whats upp, facetime, regular phone, skype etc, please write your initials here to consent the use of a non-secure platform:

I understand the following with respect to tele-health:

  1. I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
  1. I understand that there are risk and consequences associated with tele-mental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
  1. I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
  1. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to tele-mental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
  1. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that tele-mental health services are not appropriate and a higher level of care is required.
  1. I understand that I am responsible for: a) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, b) ensuring security on my computer, and c) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.
  1. I understand that during a tele-mental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call me at ______________ to discuss since we may have to re-schedule.
  1. I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

Emergency Protocols

I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life-threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.


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Working days

  • Weekdays 9:00 - 20:00
  • Friday 9:00 - 20:00
  • Saturday 10:00 - 18:00
  • Sunday Closed

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