• Telehealth Client Consent & Agreement

  • MM slash DD slash YYYY
  • -PURPOSE: The purpose of this form is to obtain your consent to participate in a telehealth visit using secure HIPAA compliant systems.
  • -NATURE OF TELEHEALTH VISIT: Telehealth involves the use of electronic communications to enable therapists to provide virtual therapy or group sessions either through HIPAA compliant software or over the phone. You will recieve a link by e-mail that allows you to access each session.
  • -MEDICAL INFORMATION & RECORDS: All existing laws regarding you access to medical information and copies of your medical records apply to this telehealth visit. Records associated with telehealth visits will become a part of your medical record.
  • -CONFIDENTIALITY: We will uphold the same principles of confidentiality while conducting telehealth visits. There are risks associated with using technology as a means of transmitting sensitive information, and there may be authorized or unauthorized access to such transmissions and records. In order to ensure confidentiality to the best of our ability. MTC will be using encryption software during telehealth visits. You are strongly encouraged to recieve your telehealth visits in a private setting.
  • -TELEHEALTH GROUPS: If you are participating in a telehealth group, be aware that the group facilitator upholds confidentiality but other group members may not. Telehealth groups are strongly encouraged to respect the privacy of other members of and keep private whatever is disclosed during group. To ensure this privacy, group members are strongly encouraged to participate in the group from a private setting and to not share links to telehealth group meetings.
  • -IDENTIFICATION: To avoid breaches of confidentiality, your therapist will take steps to confirm your identity at the beginning of each individual telehealth session. Therapists will also verify your current phone number and physical address to retain contact should connectivity be lost or should emergency personnel be needed to help you in a medical emergency. For telehealth group meetings, you will only be asked to identify yourself by name.
  • -RIGHTS: You may withhold or withdraw consent to telehealth visits at any time without affecting your right to future care or treatment.
  • -RISKS, CONSEQUENCES, & BENEFITS: Telehealth visits help to maintain access to care when in-office visits are not feasible. However, you may experience technological difficulties such as interrupted internet connection, lagging or freezing of video transmission, delays in sound, etc., that could impair the quality of therapy you receive should connection or format issues causes misunderstandings between you and your therapist. Should the technology fail during a session, please plan to continue via phone. Although MTC will do our best to uphold confidentiality standards, we are aware that there are inherent risks associated with using technology as a means of service.
  • -ALTERNATIVE SERVICES: In the event that in-person therapy is not possible at MTC and you cannot access or choose to not access telehealth sessions, MTC will provide you with appropriate referrals to equivalent mental health services.
  • -CRISIS: If you are in crisis outside of a telehealth session, please contact the MTC crisis line (336-525-9090), the National Suicide Prevention Hotline (1-800-273-8255), 911, or visit https://crisissolutionsnc.org for your local crisis team.
  • -SOCIAL MEDIA: Though telehealth is an internet-based modality, using telehealth does not imply an open digital relationship with your therapist. To maintain confidentiality and professional boundaries, your therapist will not interact with you on any social media or other internet platforms.
  • -BILLING AND SCHEDULING: Telehealth sessions can be scheduled just like normal sessions.

  • In efforts to efficiently manage our telemedicine treatment module, Mood Treatment Center requires a credit card be placed on file for any telemedicine or phone appointments. The card placed on file will be run the day of your Telemedicine or phone appointment. Please note, the estimated cost share charged to the card will be based on what your insurance company tells us you will owe for each visit.
  • If you do not wish to place a card on file, you are more than welcome to schedule an office visit with your provider(s) at which time we can collect your cost share when you check in.
  • -On the day of my appointment for my estimated cost share based on information provided to Mood Treatment Center by my insurance company
    - for late cancellation or missed appointment fees associated with a telemedicine or phone appointment.
  • I understand that Telemedicine and phone services are optional and if I do not wish to place a card on file I have the option of an in office visit. This authorization will expire 12 months from the date signed.

  • By initialing below you agree that this agreement and any other documents to be delivered in connection herewith may be electronically signed, and that any electronic signatures appearing on this agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

  • DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.