General Consent for Therapeutic Services - Vida Clinic
Description of Services
At Vida Clinic we provide individual, group and family therapy services for behavioral, emotional and social concerns. Your therapist will work with you to provide the most effective treatment possible. The treatment approach and goals will be individually based and developed in collaboration between you and your therapist. Response to therapy is different for each person and should be discussed on an ongoing basis with the therapist.
Vida Clinic serves as a training site for students in clinical training, such as graduate students in psychology, counseling and social work, and trainees’ work is directly supervised by a licensed clinician such as a licensed psychologist. Trainees will identify themselves as trainees and will clearly communicate who is their supervisor. You have the right to inquire fully about the credentials, education, and experience of your therapist and to have your questions answered to your satisfaction.
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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