Gloria M. Paz
License MFC 36754
415-235-5747
Email:psicologagmpaz@gmail.com
 

Teletherapy Consent

 
Welcome to my practice. This document contains important information about my professional services and business policies and how they may affect you. Please read carefully and make note of any questions you want to discuss with me. Once you sign this document it will become a binding agreement between us and also provide your consent for us to begin therapy.
This form is designed to allow you to give informed consent for the use of video technology for online therapy. Read it thoroughly for understanding and ensure that all of your questions are answered before signing to give consent. This is to be used in conjunction with, but does not replace, the Informed Consent document that is required of all clients prior to starting therapy services.
I understand that therapy conducted online is technical in nature and that problems may occasionally occur with internet connectivity. Difficulties with hardware, software, equipment, and/or services supplied by a 3rd party may result in service interruptions. Any problems with internet availability or connectivity are outside the control of the therapist and the therapist makes no guarantee that such services will be available or work as expected.
If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, I agree to call my therapist back at the number that I currently have for them.
I AGREE TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON MY OWN COMPUTER AND IN MY OWN PHYSICAL LOCATION.
I understand I am solely responsible for maintaining the strict confidentiality of my user ID and password and not allow another person to use my user ID to access the Services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation.
I understand that there will be no recording of any of the online session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.
Consent to Treatment: I, voluntarily agree to receive online therapy services for an assessment, continued care, treatment, or other services and authorize my therapist to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive through my therapist at any time.
AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION (ROI)
To provide you the best care possible,I will share information and communicate with your other health care providers.
We would also like your permission to talk with important support people in your life, such as family members, social
workers, probation officers, social services, and other agencies involved in your treatment.
Who are people that we should share information with to improve your care?
Are you okay with me talking with and sharing your information with?
I will only share the minimal amount of information needed related to your care. Do you have any limitations that you would like to talk with me about?
Unless consent is revoked, this authorization shall be in place until the date we pick to end the consent (may be 1 to 10 years) or upon discharge from my Services, Behavioral Health and Recovery Services, whichever occurs first.
TELEHEALTH INFORMED CONSENT FORM (required for all clients participating in telehealth)
I may be providing you services at times using videoconferencing equipment. When we do this, you will be able to see and hear me and I will be able to see and hear you, just as if we were in the same room. Are you okay with participating in services by video and/or phone when it is appropriate? Telehealth can improve your access to care by allowing you to be at a different location than me.
You are not required to participate in video if you are uncomfortable and may schedule a telephone session instead. Safety measures are being used to ensure that videoconferencing is secure, and no part of the encounter will be recorded without your consent. You have the right to withdraw consent to the use of telehealth in the course of my care at any time, without affecting your right to future care or treatment. The laws that protect your privacy and confidentiality of medical information also apply to telehealth.
Agreement
By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me. I have read this information fully and completely, I have discussed any questions I had about the information, and I understand the information. I acknowledge that it is my choice to participate in my psychotherapy (or have my child participate). I realize that the outcome of therapy depends upon my personal investment in the therapy process. I have familiarized myself with the fees for charges provided by Gloria M. Paz LMFT, and I understand and agree that the therapeutic services rendered will be charged to me and not to any third-party payer. I acknowledge responsibility for payment of these services.
Please fill out the next form to complete Your E-Signature: