Hope & Faith Wellness Clinic - Informed Consent
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I understand the following with respect to Telepsychiatry health:

1) I understand that I have the right to withdraw consent at any time without affecting my right to
future care, services, or program benefits to which I would otherwise be entitled.

2) I understand that there are risks, benefits, and consequences associated with Telepsychiatry,
including but not limited to, disruption of transmission by technology failures, interruption and/or
breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

3) I understand that there will be no recording of any of the online sessions by either party. All
information disclosed within sessions and written records pertaining to those sessions are confidential
and may not be disclosed to anyone without written authorization, except where the disclosure is
permitted and/or required by law.

4) I understand that the privacy laws that protect the confidentiality of my protected health information
(PHI) also apply to Telepsychiatry unless an exception to confidentiality applies (i.e., mandatory
reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional
health as an issue in a legal proceeding).

5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic
symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be
determined that Telepsychiatry services are not appropriate and a higher level of care is required.

6) I understand that during a Telepsychiatry session, we could encounter technical difficulties resulting
in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within
ten minutes, please call us at (470) 738-3668 to discuss since we have to re-schedule.

7) I understand that my therapist may need to contact my emergency contact and/or appropriate
authorities in case of an emergency.

Full Name: *
DOB: *
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Age: *
I hereby consent to participate in Telepsychiatry with HOPE & FAITH WELLNESS CLINIC, as part of my PSYCHIATRIC SERVICES. I understand Telepsychiatry is the practice of delivering Psychiatrist services via technology assisted media or other electronic means between a Physician and a client who are located in two different locations. This Included phone calls, emails and SMS as forms of communication. *
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