FREQUENTLY ASKED QUESTIONS about telehealth at www.lgcounseling.com/telehealth
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 www.lgcounseling.com/about-us
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.