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.”

Your provider typically provides telemental health services using the following tools: Zoom, DoxyMe or GoogleMeet
1. You will need access to Internet service and technological tools needed to use the above-listed tools in order to engage in telemental health work with your provider.
2. If you have any questions or concerns about the above tools, 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
1. Receiving services via telemental health allows you to:
2. Receive services at times or in places where the service may not otherwise be available.
3. Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings.
4. Receive services when you are unable to travel to the service provider’s office.
5. 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 services via telemental health has the following risks:
Telemental health services can be impacted by technical failures, may introduce risks to your privacy, and may reduce your service provider’s ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples:
1. Internet connections and cloud services could cease working or become too unstable to use.
2. 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.
3. Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out.
4. 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 If Telemental Health Is a Fit for You
- Although it is well validated by research, 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 may advise that you attend in-person sessions with her or will help you find other in-person providers with whom to continue services that are most convenient for you, if necessary.
- 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 communications in case of technology failures and a plan for responding to emergencies and mental health crises. In addition to those plans, your provider has the following policies regarding communications:
Our office will respond to your messages within 48 hours during normal business hours, Monday-Friday, 9:00 am to 5:00 pm, Central Time. Please note that our office may not respond at all on weekends or holidays. Our office may also respond sooner than stated in this policy. That does not mean they will always respond that quickly.
Our work is done primarily during our scheduled appointments. Contact between sessions should be limited to:
     - Confirming or changing appointment times
     - Billing questions or issues
Please note that all messages you exchange with your provider, e.g. emails and text messages, will become a part of your health record. After receiving your written permission, your provider may coordinate care with one or more of your other providers. Your provider will use reasonable care 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. You will need to provide permission for your provider to communicate with this person about your care during emergencies.

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.

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.

As with all things in 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 your provider has supplied for communications. You agree to hold your provider harmless should your protected health information be accessed in an unauthorized manner from your accounts or devices due to lack of security features, hacking, or other unforeseen intrusions.

Recordings
Please do not record video or audio sessions without your provider’s consent, and doing so may be a violation of state privacy laws. Making recordings can quickly and easily compromise your privacy, and should be done so with great care. Your provider will not record video or audio sessions.

CONSENT FOR TELEHEALTH CONSULTATION/VISIT
By signing this document, I acknowledge:

I understand that my health care provider is providing the opportunity for me to engage in a telehealth consultation/visit.

My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation/visit will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

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

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

I understand that the capture (including screenshots or photos of the therapy session), saving, or dissemination of any personally identifiable images or information from the telehealth interaction to any other entities shall not occur without my explicit written consent. CCFC also agrees to under no circumstances take any personally identifiable images from the session or store any of these images on our own devices from telehealth sessions.

I also understand that my telehealth appointment time is reserved exclusively for me. If I cannot attend my scheduled appointment, I will contact my therapist directly at least 72 hours before the session start time to reschedule. If I do not provide 72 hour notice for non emergency reasons a late cancellation fee will apply.

Similarly, if I am late to my scheduled session, I will receive my service for the remainder of my scheduled session time slot without refund.

Also, due to certain licensing requirements I agree to be physically in Texas each session and to give my current physical address accurately at the beginning of each session. I agree to tell my therapist at the beginning of each session if I am having any suicidal or homicidal thoughts.

In the case that the client is a minor child, the child’s parent or guardian agrees to help support their child in finding a confidential and private space. The parent also agrees to be either physically present at the location OR available via phone for the duration of the session and 15 minutes prior and after the scheduled session time. The parent must be willing and able to join the session at any time if requested.

Telehealth is NOT Emergency Services and in the event of an emergency, I will use a phone to call 911 or proceed immediately to the nearest hospital emergency room,

To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me.

That I fully understand its contents including the risks and benefits of the procedure(s).

That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

I understand that I have the right to withhold or withdraw my consent to the use of telemental health services in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting
CCMC at 936-760-1880.