CLS Informed Consent for Virtual Support
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As counselors, our goal is to continue to deliver individual, short-term counseling services and support as consistently as possible. By requesting and agreeing to virtual support you are acknowledging the following:

• Despite best efforts to ensure secure technology and confidentiality, there is always a risk that the transmission could be breached and accessed by unauthorized persons.

• I am aware that there is a risk of being overheard by anyone near me if I am not in a private room. I understand I am responsible for creating my own comfortable and safe space for the session.

• I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call me to discuss since we may have to re-schedule.

Child's Name *
Child's Grade *
Parent Name *
I have read and understand the limitations of virtual counseling as outlined above. I give consent for virtual support. *
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