General Consent for Therapeutic Services - Vida Clinic
Consent for Teletherapy Services
Prior to starting video-conferencing services, you agree to the following:
There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.
Confidentiality still applies for teletherapy services, and nobody will record the session without the permission from the others person(s).
We agree to use the video-conferencing platform Google Meet for our virtual sessions, and Vida Clinic will explain how to use it.
You need to use a smartphone, tablet or laptop during the session. It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
It is important to use a secure internet connection rather than public/free Wi-Fi.
It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the therapist in advance by phone, text or email.
We will develop a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
We will develop a safety plan that includes at least one emergency contact and the closest ER to your location, in the event of a crisis situation.
If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in teletherapy sessions.
I acknowledge that by clicking this box and typing my name below that I am providing my legal signature electronically.
Signature of Client (Please type your full name)
Please select one:
I am over the age of 18 and seeking services for myself
I am a legal guardian seeking services for a child
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