I hereby consent to participate in telehealth with Family Guidance Center, PLLC. I understand that telehealth 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 located in two different locations. This agreement supplements the general informed consent which was completed at the start of therapy. I understand the following with respect to telehealth:

1. I have the right to withdraw consent at any time without affecting my right to future care or services to which I would otherwise be entitled.
2. There are risks, benefits, and consequences associated with telehealth, 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. 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. The privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth 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. If I am experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care is required.
6. During a telehealth session, we could encounter technical difficulties resulting in service interruptions, which may result in rescheduling or canceling the appointment.
7. I agree to inform my therapist of my current location at the beginning of each session.