PFHL Consent for Online/Virtual Mental Health Treatment
The following policies will help you understand our processes and procedures. Please agree to all the following to give consent to online/virtual treatment.  Please AGREE to each section and SIGN and DATE at the end.
Sign in to Google to save your progress. Learn more
Email *
(First and Last) Name of Patient: *
Date of Birth of Patient:   *
(First and Last) Name of Person Completing This Form: *
Relationship of Person Completing This Form to Patient: *
Identify Verification - All patients will have to verify their age and identity by showing their drivers license or other verifiable governmental identification. *
Technology - Providers for Healthy Living's online providers will use HIPAA compliant video services. *
Technology - The patient is responsible for securing his or her own computer hardware, internet access points, and password security. *
Technology - Providers for Healthy Living is not liable for confidentiality breaches when they are caused by patient error. *
Technology - Providers for Healthy Living is not responsible for their patient’s equipment failure, e.g. camera, and/or internet service. *
Technology - Providers for Healthy Living is not responsible for lapses in confidentiality that are in direct response to the patient's actions. *
Disconnection Problems - If video services are not available due to an unplanned equipment or service malfunction, sessions will occur via telephone. *
Recordings Are Prohibited - Patients are not allowed to make an audio or video recording of any portion of the session. *
Risk of Harm - Online mental health treatment is not a crisis-based clinical service. *
Risk of Harm - Online mental health treatment may not be appropriate for patients with active suicidal or homicidal thoughts or patients who are experiencing acute mental health problems, such as manic or psychotic symptoms. *
Risk of Harm - It is the responsibility of the patient to inform their Providers for Healthy Living clinician if they are at risk of harm to self or others. *
Risk of Harm - At intake, a patient who reports being at risk of harm to self or others will not be offered online mental health services from Providers for Healthy Living. *
Risk of Harm - If through the intake evaluation or subsequent sessions, a patient is deemed to be at risk of harm to self or to others, Providers for Healthy Living will terminate the sessions, while providing alternative treatment options. *
Risk of Harm - If a patient who was not formerly at risk should become at risk of such harm to self or others, they must immediately report it to their Providers for Healthy Living provider.  In such cases, a patient may be referred to a traditional program or provider. *
Confidentiality Restrictions - The laws that protect the confidentiality of any medical information also apply to online mental health treatment. *
Confidentiality Restrictions - Information about the patient will only be released with his or her express written permission, with the exceptions of the following cases:  (1) if the provider determines risk of self-harm, (2) if the provider determines risk of harm to others, (3) if the provider is informed about or suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult, or (4) if the provider believes that someone’s mental condition leaves the person gravely disabled. *
Records - The provider will maintain records of online treatment and/or consultation services. *
Records - All clinical records will be maintained as required by applicable legal and ethical standards according to the various professional licensing boards, i.e. American Counseling Association, National Association for Social Workers, American Medical Association, American Psychological Association, etc. *
Payments - Payment is expected at the time of service for all online visits.  Some insurance companies allow for online mental health treatment.  Some don't.  If a patient's insurance company denies the visit for online treatment, he or she will be responsible for the full cost of the visit ($80 for therapy with a counselor or therapist, $100 for therapy with a psychologist, $125 for medication management or therapy with a medical provider, $150 for an intake with a therapist, and $250 for an intake with a medical provider). *
CANCELLATIONS AND NO-SHOW POLICY:  Once your appointment is scheduled, you will be expected to attend unless you provide at least 24 hours advanced notice of cancellation. If you do not provide at least 24 hours notice, or fail to show for a scheduled NEW medication or therapy appointment, you will be responsible for a $150 no-show charge and if you fail to show for a scheduled FOLLOW-UP appointment, you will be responsible for a $100 no-show charge. Missing a group will result in a $30 no-show charge, and missing a testing appointment will result in a $275 charge.  There is a $50 late cancellation charge for all appointments cancelled less than 24 hours in advance of the scheduled appointment time. Please note: these fees must be paid before future appointments will be scheduled or medication refills will be given. If you arrive late and miss half of your scheduled appointment time, you will be rescheduled and will charged a late cancellation fee. *
No Shows or Late Cancellations - No show fees must be paid before the patient receives his or her next online or office session with a Providers for Healthy Living provider. *
EXCESSIVE NO SHOWS OR LATE CANCELLATIONS:  Consistency is the key to improving and maintaining your or your child's mental health. To this end, if your absences (late cancellations or no shows) become clinically interfering, you or your child will likely be dismissed from our practice. A certified letter will be sent notifying you of this decision, in the unfortunate and unlikely event that this may occur. *
Patients have the right to refuse consent or withdraw consent for treatment at any time by informing any staff member. *
CLIENT SIGNATURE - By typing your name below, you certify that you understand the risks and limitations to online mental health treatment.  (Please type the full legal name of the person completing this form.  By doing so, you agree that your typed signature has the same validity and meaning as your handwritten signature.) *
Date Signed: *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Providers for Healthy Living, LLC. Report Abuse
Google Forms