Telehealth Disclosure Statement —Chadwick Royal, PhD, LCMHCS
This form should be reviewed and completed before your first appointment if receiving services via telehealth

- You will need access to certain technological services and tools to engage in telemental health-based services.
- Telemental health has both benefits and risks, which you and and your provider will be monitoring as you proceed with your work.
- It is possible that receiving services by telemental health will turn out to be inappropriate for you, and that you and your provider may have to cease work by telemental health.
- You can stop work by telemental health at any time without prejudice.
- You will need to participate in creating an appropriate space for your telemental health sessions.
- You will need to participate in making a plan for managing technology failures, mental health crises, and medical emergencies.
- Your provider follows security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy.
What is Telemental Health?

“Telemental Health” means, in short, “provision of mental health services with the provider and recipient of services being in separate locations, and the services being delivered over electronic media”.

Services delivered via telemental health rely on a number of electronic, often Internet-based, technology tools. These tools can include videoconferencing software, email, text messaging, virtual environments, specialized mobile health apps, and others.

Your provider typically provides telemental health services using the following tools:
- VSee videoconferencing software (HIPAA compliant)

You will need access to Internet service and technological tools needed to use the above-listed software in order to engage in telemental health work with your provider.

If you have any questions or concerns about the above software tool, please address them directly to your provider so you can discuss their risks, benefits, and specific application to your treatment.
Benefits and Risks of Telemental Health

Receiving services via telemental health allows you to:

- Receive services at times or in places where the service may not otherwise be available.
- Receive services in a fashion that Amy be more convenient and less prone to delays than in-person meetings.
- Receive services when you are unable to travel to the service provider’s office.
- The unique characteristics of telemental health media may also help some people make improved progress on health goals that may not have been otherwise achievable without telemental health.

Receiving service via telemental health has the following risks:

- Internet connections and cloud services could cease working or become too unstable to use.
- Cloud-based service personnel, IT assistants, and malicious actors (“hackers”) may have the ability to access your private information that is transmitted or stored in the process of telemental health-based service delivery.
- Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out.

Interruptions may disrupt services at important moments, and your provider may be unable to reach you quickly or using the most effective tools. Your provider may also be unable to help you in-person.

There may be additional benefits and risks to telemental health services that arise from the lack of in-person contact or presence, the distance between you and your provider at the time of service, and the technological tools used to deliver services. Your provider will assess these potential benefits and risks, sometimes in collaboration with you, as your relationship progresses.
Assessing Telemental Health’s Fit for You

Service delivery via telemental health is not a good fit for every person. Your provider will continuously assess if working via telemental health is appropriate for your case. If it is not appropriate, your provider will help you find in-person providers with whom to continue services.

Please talk to your provider if you find the telemental health media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the telemental health medium seems to be causing problems in receiving services. Raising your questions or concerns will not, by itself, result in termination of services. Bringing your concerns to your provider is often a part of the process.

You also have a right to stop receiving services by telemental health at any time without prejudice. If your provider also provides services in-person and you are reasonably able to access the provider’s in-person services, you will not be prevented from accessing those services if you choose to stop using telemental health.
Your Telemental Health Environment

You will be responsible for creating a safe and confidential space during sessions. You should use a space that is free of other people. It should also be difficult or impossible for people outside the space to see or hear your interactions with your provider during the session. If you are unsure of how to do this, please ask your provider for assistance.
Our Communication Plan

At our first session, we will develop a plan for backup communication in case of technology failures and a plan for responding to emergencies and mental health crises.

The best way to contact me between sessions is to call by telephone at 336-684-0697, send a text to the same number, or email me at

I will respond to your messages within 24 hours. Please note that I may not respond at all on weekends or holidays, unless it is an emergency.

Our work is done primarily during our appointed sessions. Contact between sessions should be limited to:
- Confirming or changing appointment times.
- Billing questions or issues.

Please note that all text messages that you exchange with me (text and email) technically become part of your health record.

If I need to coordinate your care with any other providers (with your written consent), I will do so to ensure that those communications are secure and that they safeguard your privacy.
Our Safety and Emergency Plan

As a recipient of telemental health-based services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with your provider.

Your provider will require you to designate an emergency contact on the client information form. You will need to provide permission for your provider to communicate with this person about your care during emergencies. Signing this statement will provide this permission.

Your provider will also develop with you a plan for what to do during mental health crises and emergencies, and a plan for how to keep your space safe during sessions. It is important that you engage with your provider in the creation of these plans and that you follow them when you need to do so.
Your Security and Privacy

Except where otherwise noted, your provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged.

There is a specific document on your provider’s website that contains information about the tools used for storing client records and other information about how client data is kept secure. This document is labeled, “Electronic Records Disclosure Statement”.

As with all things telemental health, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example, when communicating with your provider, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that provider as supplied for communication.
Acceptance of terms

By typing your name below (aka, signing), you are stating that

“I agree to these terms and will abide by these guidelines” (Parent/Guardian signs if client is a minor).

Signature - Please type your full name here
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