TELE-THERAPY POLICY AND INFORMED CONSENT

CenterPoint Counseling and Consulting offers Tele-Therapy; an individual, outpatient treatment modality that occurs via live, interactive video-conferencing, in lieu of or in addition to in-person sessions. It includes both audio and visual components that allow you to receive mental health services remotely.
Details: Confirm you have access to the technology needed to participate in video-conferencing. This includes a strong, reliable internet connection and one of the following: Computer (desktop or laptop) with a video camera; tablet with a video camera; mobile device. Ensure you have the ability to create a safe and confidential space during sessions for 50-55 minutes.
What to Expect: Verify your identity as the identified client, parent or guardian, including DOB. Verify your Clinician’s name, credentials and location. Review this Telehealth Policy and verify contingency procedure of re-establishing electronic or other connection if communication is terminated. Verify your physical location. You must be in the state of Pennsylvania at the time of the session. Confirm that there is no one present in your location who is not permitted to hear or share personal health information. Tele-therapy sessions will follow the same therapeutic process of an in-person session. Agreed upon treatment plan goals will be addressed and worked on. Prior agreement to Consent to Treat applies. Client has the right to accept or reject any treatment. Tele-therapy is a voluntary, outpatient service.
Technical Details: Online therapy is technical in nature and problems with technology may occur. If something beyond our control disrupts the connectivity of our session, all parties should attempt to reconnect to the video call. If after 10 minutes, the video call is repeatedly unsuccessful, we can complete the session by telephone. You also have the right to stop receiving teletherapy services at any time without prejudice. If your clinician also provides services in-person, has alternative openings in their schedule and you are able to access the clinician’s in-person services, you will not be prevented from accessing those services if you chose to stop using teletherapy services.
Confidentiality: Because online therapy utilizes the Internet for the transmission of personal information, CenterPoint Counseling and Consulting is not responsible for limits of security within the World Wide Web. CenterPoint Counseling and Consulting exclusively utilizes Telehealth platforms that meet or exceed HIPAA requirements of privacy protection and encryption, including Regroup, Zoom and Doxy.me.
Recordings: Audio and/or video recordings are strictly prohibited without your clinician’s and client’s written consent. Privacy is compromised with recording.
Harm to Self or Others: If there is an emergency during your session, where the clinician is concerned about your personal safety, or the safety of others (the possibility of you injuring someone else) your clinican must follow PA. Duty To Warn requirements; including contacting law enforcement, hospital or an emergency contact whose name you have provided.
Financial Agreement: Payment information is collected prior to the Initial Intake and thereafter follows signed Assignment of Benefits details and will be billed and followed accordingly. Policies for late cancellations and missed appointments for tele-therapy are the same as for in-person sessions. Tele-therapy sessions will be paid for following the completion of the session and may be sent in by mail or paid online through credit card or PayPal at the web site www.centerpointtherapist.com
Agreement to Tele-Therapy Policy: My signature below indicates my understanding and agreement to the Tele-Therapy Policy and Informed Consent. If I am in need of crisis intervention, I agree to call 911, proceed to the nearest emergency room, or contact a crisis hotline.
Client Signature
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Witness Signature (For Office Use Only)
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