Informed Consent for Telehealth

I hereby consent to engage in teletherapy with my therapist. I understand that teletherapy includes consultation, diagnosis, treatment, transfer of medical data, emails, telephone conversations, and education using interactive audio, video, or data communications. I understand that teletherapy involves the communication of my medical and mental health information both orally and visually.

My Rights Concerning Teletherapy Include:

1. I may withhold or withdraw consent at any time without affecting my right to future care or treatment.
2. The laws protecting the confidentiality of my medical and mental health information also apply to teletherapy. Confidentiality, exceptions, and limits are detailed below.
3. Risks of teletherapy include possible:
   • Technical failures (disruption or distortion of information)
   • Unauthorized access to information transmission or storage
   • Limitations in effectiveness compared to in-person care
4. If my therapist determines that teletherapy is not clinically appropriate, they will discuss alternatives or provide referrals.
5. I understand that the benefits of teletherapy may include improved access to care, but outcomes cannot be guaranteed.
6. Teletherapy is not appropriate for emergencies. If I am in crisis, I will call 911, 988, or go to the nearest hospital. For 24/7 support, I can call the Suicide & Crisis Lifeline at 1-800-273-TALK (8255).
7. I am responsible for:
   • Providing a computer, internet, and private space
   • Ensuring the privacy and security of my devices and environment
   • Preventing interruptions during sessions
8. I understand that email communication is not secure and may risk confidentiality.
9. I have the right to access my medical information and records under HIPAA and applicable law.

The Process of Counseling/Evaluation and Scope of Practice

Therapy is a process—a working partnership between client and therapist. Therapy is not always comfortable or straightforward, as difficult emotions and patterns often have to be sorted through for change to occur. Clients should feel comfortable with their therapist and be able to ask about anything on their mind regarding the process.

There are risks and benefits associated with counseling:

• Risks: Sometimes you may feel worse before you feel better. Clients often evaluate their relationships, and some choose to end friendships or romantic partnerships that no longer serve them.
• Benefits: Counseling can promote mental, emotional, spiritual, and physical wellness. While results vary, most clients who complete counseling report reduced symptoms, an improved ability to cope with life stressors, and a more optimistic outlook.

Treatment Plans

By approximately your second visit, your therapist will discuss their working understanding of the issues you face, your therapeutic goals, the treatment plan, and potential outcomes of counseling. If you have any questions about procedures or your treatment plan, please ask your therapist to explain.

Termination

After your first session, your therapist will assess if they can be of benefit to you. Therapists do not accept clients they believe they cannot help. If at any point your therapist determines counseling is not effective for you, they will terminate services and provide referrals. You have the right to terminate counseling at any time.

Dual Relationships

Dual relationships exist when a therapist has another role in your life (e.g., friend, business associate). Your therapist will not accept you as a client if a significant dual relationship exists. Not all dual relationships are unethical or avoidable. Counseling never involves dual relationships that impair the therapist’s objectivity or clinical judgment or are exploitative.

It is your responsibility to inform your therapist if a dual relationship arises or you feel uncomfortable. Your therapist will always listen and respond to your feedback and will discontinue the dual relationship if it interferes with counseling or your welfare.

Social Networking and Internet Searches

Your therapist will not accept friend requests from current or former clients on social media (Facebook, LinkedIn, etc.), as it violates ethical standards and may compromise confidentiality. Your therapist requests that you do not contact them via social networking sites.

Confidentiality

Everything shared in sessions and your therapist’s notes are confidential and may not be released without your written permission, except where disclosure is required by law.

Exceptions to Confidentiality:

1. If you threaten to harm yourself or another person, your therapist is legally and ethically required to take action, which may include notifying the intended victim, arranging hospitalization, notifying family or support systems, and/or alerting law enforcement.
2. If abuse or neglect of a child, elder, or disabled person is known or suspected, your therapist must report it to the appropriate state agency.
3. If your therapist receives a Court Order for records or testimony, they are legally required to comply.

Disclosure of Medical Information:

You understand that Allswell and Allswell Health Medical Group PA may disclose protected health information (PHI) for treatment, payment, health care operations, and other purposes described in our Notice of Privacy Practices. This may include PHI related to infectious diseases (including HIV/AIDS), substance use, genetic information, and mental/behavioral health. Disclosures may be made to other providers, health plans, payers, service providers, affiliates, contractors, and subcontractors who support operations.

Assignment of Benefits (if applicable):

If I choose to use insurance to pay for services, I authorize payment of insurance benefits directly to Allswell Health Medical Group PA for services provided. I understand that I am financially responsible for any charges not covered by my insurance plan, and for all charges if I choose to self-pay.

Medical Documentation:

You consent to Allswell and its affiliates, contractors, and subcontractors using text transcription to accurately document session notes.

Emergencies and Crises

If you have a life-threatening emergency, call 911, 988, or go to the nearest hospital. Your safety is the top priority. Safety plans will be developed for emergencies. Notify your therapist once it is safe to do so.

Licensing and Ethical Information

Your therapist is a licensed or registered mental health professional in specific states and may only provide services to clients located in states where they are licensed. If you have a complaint about a provider, you may submit it to Allswell via the patient portal. If your complaint cannot be resolved by the Allswell team, you can contact the relevant state licensing board.

Maryland Notice:

What You Should Know: The knowledge, experience, and qualifications of consultants providing data to the telehealth provider may not be fully known to the provider. The quality of transmitted data may impact services. Changes in environment or test conditions during telehealth may not be possible. Telehealth services may not be provided by correspondence only. (Md. Code Regs. 10.41.06.04)

Relevant board contact information:

https://www.mbp.state.md.us/resource_information/

Board of Social Work Examiners
4201 Patterson Avenue
Baltimore, MD 21215
Tel: 410-764-4788

Board of Professional Counselors and Therapists
4201 Patterson Avenue
Baltimore, MD 21215
Tel: 410-764-4732