F W Joseph and Associates, LLC
Informed Consent for Teletherapy
I, hereby consent to participate in teletherapy with, Frank W. Joseph III, LPC-S, as part of my psychotherapy. I understand that teletherapy is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are separated by distance.
I understand the following with respect to teletherapy:
1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
2) I understand that there are risks, benefits, and consequences associated with teletherapy, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to teletherapy unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that teletherapy services are not appropriate and a higher level of care is required.
6) I understand that during a teletherapy session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call me at (504)349-8739 to discuss since we may have to re-schedule or continue the session via telephone.
7) I understand that payment arrangements will be made at intake. Health plans may only cover part of the therapy fees. There are two kinds of costs that may be are not covered by the insurance company - deductibles and copays. I am responsible for paying any non-insured portion of the fee before each visit.
8) I understand that text messaging via mobile phone is acceptable for appointments and housekeeping issues only. Regarding phone calls, I am aware that unless both parties are on land line phones, the conversation may not confidential.
9) I understand that It is my responsibility to communicate through a computer that is safe i.e. wherein confidentiality can be ensured. It is recommended that I fully exit all online counseling sessions and emails.
10) I understand that If it is determined that I would be better served by another mental health provider, I will be assisted with the referral process.
11) I understand that if I am currently receiving services from another mental health professional, I am expected to inform my therapist. My therapist may find it helpful to share information with my primary care physician or other health and mental health professionals who are currently treating me.
12.) I understand that my therapist will provide services consistent with the jurisdictional licensing laws and rules of the State of Louisiana and all relevant regulations regarding teletherapy.
13) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
Emergency Protocols
I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life- threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.