Informed Consent for Technology Assisted Services
FREQUENTLY ASKED QUESTIONS about telehealth at
OVERVIEW: By signing this form, you acknowledge that you are a patient or authorized patient representative of LG Counseling, PLLC, that you have been informed of the technology-assisted operations of LG Counseling, PLLC, and that you consent to conducting patient-related services in such manner as outlined and agreed to below.
You acknowledge that electronic communication via e-mail, text and mobile phone between you and any representatives/therapists at LG Counseling, PLLC may not be completely secure. While LG Counseling, PLLC will take all reasonable efforts to protect your confidentiality in compliance with HIPPA regulations, there remains some risk that any protected health information contained in unsecured email, text or mobile phone records may be intercepted by unauthorized third parties.
While there are minimal risks to engaging in technology-assisted services, there may be times when such services are essential to ensuring client care continuity. You acknowledge that your therapist reserves the right to determine on an on-going basis whether the patient condition being assessed and/or treated is appropriate for technology-assisted services.
WITHDRAWAL/MODIFICATION: You have the right to withdraw and/or modify your consent to receive non-secure forms of electronic communication. You can do this by accessing this form at any time, and editing your original response.
FEES: There are no additional fees beyond your normal session fees for making use of such technology-assisted services.
CREDENTIALS: All of our therapists and their credentials can be accessed on our website, at
NOTE: LG Counseling, PLLC continues to exceed applicable federal and state legal requirements of health information privacy, including HIPPA compliance and state privacy, confidentiality, and security rules.
ALL OF THE INFORMATION IN THIS FORM IS CONFIDENTIAL AND SECURE.
If you have an upcoming appointment scheduled with us and have a fever, cough and/or difficulty breathing, have traveled to or had close contact with someone who has traveled to high risk states/countries, or have tested positive for or been exposed to someone with COVID-19, we may ask you to communicate via teletherapy as an option for your upcoming appointment.
CONSENT: By checking the boxes below and signing this consent, I give permission for LG Counseling, PLLC to contact me using the non-secure methods indicated below, even if the communication includes protected health information or other confidential information. I understand that email, text and mobile phone communications are inherently unsecure and that there are risks associated with using these forms of communication:
Zoom.us - Online platform for Video and Audio Communication that is HIPPA compliant
Patient Name [This constitutes your electronic signature]
Name of Authorized Patient Representative and Patient Relationship (if patient is a minor). [This constitutes your electronic signature]. [Format: Name - Relationship]
Individual Counseling: Select Your Therapist
Group Counseling - Select Your Group
Parents of Children with Special Needs
Living On My Own
The client seeking services is over the age of 18
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