Informed Consent for Tele-mental Health Services
Prior to starting Zoom, FaceTime or Tele conference calls we discussed and agreed to the following.
Initial *
There are potential benefits and risks with telemedicine.
Initial *
Confidentiality still applies for tele-mental health services.
Initial *
We agree to use the platform that is comfortable for you.
Initial *
It is important to use a secure internet connection rather than public free Wi-Fi.
Initial *
It is important to have a quiet setting for the best results.
Initial *
I would like to record our session with your permission.
Initial *
We need a back up plan incase of technical difficulties (phone number where you can be reached to restart or reschedule an apt.)
Initial *
We need a safety plan that includes at least one emergency contact and the closest ER to your location.
Initial *
As your nurse practitioner I may determine that due to certain circumstances tele mental health is no longer appropriate and that we should see other in person.
Patient Name *
Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy