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Permission for Telehealth
Phoenix Tree Counseling, LLC
100 Executive Drive
Suite K
Lafayette, IN 47905
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Email *
Client Name *
Client Date of Birth *
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Consent to use Google Meet

Telehealth by Google Meet is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge telehealth by Google Meet is NOT an emergency service. In the event of an emergency, I will  call 911.

Telehealth by Google Meet facilitates videoconferencing and is not responsible for the delivery of any healthcare and/or medical advice. I do not assume that my provider has access to any or all of the technical information in the Google Meet Service – or that such information is current and/or accurate.I will not rely on my health care provider to have any of this information by Google Meet Service. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
General telehealth information
I hereby authorize Phoenix Tree Counseling, LLC to use HIPPA compliant and secure telemedicine technology for our sessions. 
I understand that there is a possibility that our technology may fail during a telehealth session and that there may be an interruption or need to reschedule. I authorize the clinician to use my address and emergency contact information as part of a safety plan, should an emergency arise. I understand that during the process, my clinician may decide that telehealth is not the most appropriate type of service for my needs and may help connect me to other health services. I understand that my clinician is only licensed to practice in the state they are licensed. I understand that if I move or travel out of the state in which they are licensed, I will need to obtain other health services. I understand that I may revoke this authorization at any time by giving my written notice. I may specify the date, event, or condition on which this content expires. If none is stated, and if no prior notice of revocation is received, this consent will expire upon termination of services.
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By typing my full name, I agree and consent to the above.
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I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document for purposes of validity, enforceability, and admissibility.
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