Informed consent for tele-therapy services

I understand that Pets52 will provide administrative services to facilitate connecting me with a licensed mental health professional (“the LMHP”) via our online platform to provide behavioral healthcare, including assessment, diagnosis, therapy, follow-up and/or education teletherapy includes consultation, treatment, transfer of personal and health information, emails, telephone conversations and education using interactive audio, video and data communications (“Telehealth”). Telehealth involves the use of electronic communications. I hereby consent to engage in Telehealth services with my LMHP. I understand that my LMHP is an independent contractor and is not employed by Pets52. My LMHP may require me to execute an additional informed consent prior to engaging in Telehealth.

I understand that the expected benefits of Telehealth are improved access to behavioral health care enabling me to remain at a remote site while the LMHP is at a distant site, more efficient evaluation and management and obtaining the expertise of a distant LMHP who is licensed in the state where I reside.

I understand that I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my personal and health information for in-person behavioral health services. Any information disclosed by me during the course of my remote Telehealth, therefore, is generally confidential to the extent provided by law.

As with any medical care, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to: (a) in rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate professional decision making by the LMHP; (b) delays in evaluation and treatment could occur due to deficiencies or failures of the equipment; and (c) the possibility of disruption, distortion or unauthorized access during transmission of personal information due to internet/electronic/technical failures beyond the control of Pets52 and my LMHP.

By signing this form, I understand the following:

• I understand that Telehealth is the use of electronic communication technologies by a health and/or therapeutic provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to the LMHP to provide mental and social services to me via Telehealth.
• I understand that I may be required to have certain system requirements to access electronic Telehealth services via the method chosen. I understand that I am solely responsible for any cost to obtain any additional/necessary system requirements, accessories, or software to use tele-behavioral health services.
• I understand that I have the right to withhold or withdraw my consent to the use of Telehealth by the LMHP at any time, without affecting my right to future care or treatment.
• I understand that a variety of alternative methods of health care may be available to me, and that I may choose one or more of these at any time.
• I represent and warrant that all required information I provided to Pets52 and the LMHP is truthful and accurate, and that I will maintain the accuracy of such information.
• I understand that there are, by law, exceptions to confidentiality by a LMHP including, but not limited to, reporting child, elder and dependent adult abuse; expressed threats of violence toward an ascertainable victim; my own mental or emotional state informing a clear danger to myself or others; where I make my mental or emotional state an issue in a legal proceeding; where otherwise required by law.
• I understand that I am solely responsible for the privacy and confidentiality in my surrounding environment while engaged in telehealth and will exercise appropriate privacy measures.
• I agree that if it becomes clear to the LMHP, in his or her sole professional opinion, that the Telehealth modality is unable to provide all pertinent clinical information during the Telehealth encounter, the LMHP will advise me prior to the conclusion of the live Telehealth encounter and will advise me regarding the need for me to obtain an additional in-person evaluation reasonably able to meet my needs and may make a referral to a LMHP in my area.
• I understand that I have a duty to inform my LMHP of electronic interactions regarding my care that I may have with other healthcare providers.
• I understand that Telehealth services may not be as complete as face-to-face services.
• I understand that there are potential risks and benefits associated with any form of treatment, and despite my efforts and the efforts of my LMHP, my condition may not improve, and in some cases may even get worse.
• I have been given an opportunity to select a LMHP prior to the consult, including a review of the consulting provider’s credentials.
• I understand there is a risk of technical failures during the Telehealth encounter beyond the control of Pets52 or my LMHP. I agree to hold harmless Pets52 and my LHMP for delays in evaluation or for information lost due to such technical failures.
• I understand that if I am experiencing a medical emergency or a crisis, that should dial 9-1-1 or contact the National Suicide Hotline 800-273-TALK (800-273-8255), as appropriate, immediately and that Pets52 is not able to connect me directly to any local emergency services or crisis hotline.
• I understand that Pets52 does not guarantee that your LMHP will issue an Emotional Support Animal letter or that a landlord, airline, or other third party will accept your ESA Letter.
• I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.

I have read and understand the information provided above regarding teletherapy and all of my questions have been answered to my satisfaction. By clicking and assigning a ‘checkmark’ in the “I AGREE” box prior to purchase, I am authorizing the LMHP to whom Pets52 facilitates a connection to assess my mental health via Telehealth and confirming my agreement and understanding of the statements above. I hereby give my informed consent and authorization for my LHMP to use Telehealth in my healthcare.

I agree that a copy of this form may be treated as a signed original.

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