Consent for Telehealth Consultation Group Therapy
Jeff Georgi & Associates
112 Swift Avenue

1. I understand that Jeff Georgi has offered to provide consultation via phone or telehealth consultation.

2. I authorize Jeff Georgi to allow us to meet via smartphone or a secure online videoconference service platform. I am aware that there may be additional charges from my internet provider.

3. Jeff Georgi has explained to me how the video conferencing technology that will be used will not be the same as a direct client/psychotherapist session due to the fact that I will not be in the same room as my provider.

4. I understand that a telehealth consultation has potential benefits including easier access to care, continuity of care, and the convenience of meeting from a location of my choosing.

5. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties, which cannot be predicted. I understand that my health care provider or I can discontinue the telehealth consult/session if it is felt that the videoconferencing connections are not adequate for the situation.

6. I understand that the telemedicine session will not be audio or video recorded at any time, and that we will both disable computer and device-generated recording to the best of our abilities.

7. I understand that it is important to connect from a quiet room, with no interruptions, where my, and/or the group’s privacy are guaranteed.

8. I understand that the limitations to confidentiality outlined in our original Consent to Service or Office Policies, apply to the videoconferencing format.

9. My consent to participate in this telemedicine service shall remain in effect for the time period we agree upon, 1 year from today, which we can modify, or until I revoke my consent in writing.

10. I agree that there have been no guarantees or assurances made about the results of this service.

11. I have had a direct conversation with Jeff Georgi, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in language which I understand.

12. I confirm that I have read and fully understand the above.
Email address *
First Name *
Your answer
Last Name *
Your answer
Date *
Signature *
By submitting this form, I am submitting my signature.
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Georgi Educational and Counseling Services. Report Abuse