CONSENT FOR TELEHEALTH CONSULTATION

1.    I understand that my provider is offering mental health services through telehealth, using videoconferencing technology.

2.    I understand I must be physically located in the state of Texas at the time of my telehealth session.

3.    I understand I will be asked to confirm my physical location at the start of each telehealth session.

4.    I understand that telehealth has potential benefits, including easier access to care, increased convenience, and the ability to meet from a private location of my choosing.

5.    I understand there are potential risks to telehealth, including technical difficulties, interruptions, unauthorized access, and limits to my provider’s ability to respond to emergencies. Either I or my provider may discontinue a telehealth session if the connection is inadequate.

6.    I understand that telehealth is not appropriate for emergencies, and I will call 911 or local emergency services if I am in crisis.

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE

Telehealth by SimplePractice is the secure, HIPAA-compliant platform we will use for telehealth sessions, communication, and paperwork. By signing this form, I acknowledge:

1.    Telehealth by SimplePractice is not a crisis service and cannot be used to contact emergency responders.

2.    SimplePractice provides the videoconferencing platform but does not provide healthcare services or advice.

3.    To maintain confidentiality, I will not share my session link with anyone unauthorized to attend.

By signing this form, I certify:

·         That I have read and understand this telehealth consent form.

·         That I fully understand the contents of this form, including the risks and benefits of telehealth.

·         That I agree to use SimplePractice as the platform for my telehealth sessions.

·         That I consent to participate in telehealth services with Embark Healing Therapy & Wellness.