I understand that:

  • Tele-mental health is delivery of professional services by using technology such as video, phone, text messages, apps and email.
  • The clinician/psychiatric provider/therapist (from herein referred to as “provider”) and the client/patient are not in the same physical location and there is no direct in person face-to-face communication.
  • There are benefits and limitations to this type of service.
  • Tele-mental health is a new delivery method for professional services and is an area not yet fully evaluated by research and may have potential risks including some that are not yet recognized
  • Tele-mental health services rely on technology which allows for greater convenience and service delivery but also carry risks in transmitting information over technology that include but are not limited to breach of confidentiality, theft of personal information and disruption of services due to technical difficulties
  • I will need access to, and familiarity with using, the appropriate technology in order to participate in this service.
  • I agree that I will use my own equipment to communicate and not equipment owned by others and specifically will not use my employer’s equipment and network. I am aware that any information I enter in my employer’s equipment/network can be considered to belong to my employer and my privacy may thus be compromised.
  • It is my responsibility to maintain privacy on my end of communication
  • My clinical history and personal health information will be discussed with myself or other behavioral health care professionals using interactive video, audio or other telecommunications technology
  • Insurance companies, individuals and entities authorized by myself and those permitted by law may also have access to records or communications
  • I understand that my tele-mental health consultations/sessions may be recorded and stored electronically as part of my medical records.
  • I agree that on my end I will not record any of my tele-mental health consultations/sessions in any format.
  • I have received no guarantee as to the effectiveness of tele-mental health consultations/sessions.
  • I understand that at any time, I may decline tele-mental health services. My provider can also, at any time, decide to terminate these services for clinical, administrative or other reasons.
  • If the need for direct, in person services arises, it is my responsibility to contact clinicians/providers such as my PCP and/or my provider’s office for an in-person appointment. I understand that an opening may not be immediately available in either office.
  • I understand that the tele-mental health consultations/sessions do not eliminate the need for in-person consultations/sessions, and I agree to comply with such in-person visits as determined appropriate by my provider.
  • I understand that prior to each tele-mental health consultation/ session, I will need to identify myself with a government issues photo ID (such as driving license or passport) to the clinic staff and/or the provider.


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.



(Primary Care Physician/PCP, Therapist, Crisis Hotline, Trusted Family or Friend, or Community Support Person)


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.