TELE-MENTAL HEALTH INFORMED CONSENT
I understand that:
I understand that I will always use an agreed upon physical location for receiving tele-mental health services. I also agree that prior to each consultation/session, I will identify my physical location to the clinic staff and/or the provider.
I agree to use one of the following locations for my tele-mental health consultations/ sessions. Any exceptions will need to be approved by my provider.
LOCAL SUPPORT/CRISIS SITUATIONS/EMERGENCIES
(Primary Care Physician/PCP, Therapist, Crisis Hotline, Trusted Family or Friend, or Community Support Person)
LIST AT LEAST TWO
I understand and agree that if I am facing or if I think I may be facing an emergency situation that could result in harm to me or to another person; I am not to seek a tele-mental health consultation. Instead, I agree to seek care immediately through my own local health care practitioner or at the nearest hospital emergency department or by calling 911.
Signature of Patient