Informed Consent for Telehealth Services • Zumbro Valley Health Center

Informed Consent for Psychotherapy Services

I understand that as a client at Zumbro Valley Health Center, I am eligible to receive a range of services. The type and extent of services that I will receive will be determined following an initial diagnostic assessment or psychiatric evaluation and through discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks, or months, and is most beneficial when scheduled appointments are attended. Zumbro Valley Health Center Customer Service completed a Financial Intake with me before meeting my clinician. At this time fees for services, third-party payment coverage, and when applicable, Sliding Scale eligibility were discussed. I received the following documents at that time. -The Notice of Privacy Practices -Financial Agreement -Grievance/Complaint Procedure -Client Rights and Responsibilities -Government Data Practices Act and procedures for reporting grievances and alleged violations of client rights -Attendance Policy As part of the informed consent process, my clinician reviewed and answered my questions regarding the following topics: -Limits of confidentiality and mandated reporting -Identification of licensure -Treatment alternatives -Possible outcomes -Side effects of treatment -Approximates length and cost of treatment -Client's rights and responsibilities in implementation of the treatment plan -Staff rights and responsibilities in the treatment process

Today's Date*

Client's Name*

First Last

Client's Date of Birth*

Is the Patient under 18 years old?*

Yes
No

Parent/Guardian Name*

First Last

Email*

Enter Email Confirm Email

Informed Consent for Telehealth Services*

I consent to telehealth services with Zumbro Valley Health Center

By signing this consent form:
• I consent to receive outpatient mental health treatment, substance use disorder treatment, or primary care services by means of telehealth technology.
• I understand that I will not physically be in the same room as my telehealth provider
• I understand that while the session is conducted via HIPAA compliant software, factors in my own environment (others present, privacy of the location) may impact the confidentiality of my sessions. It is in me best interest to be in a location that is private and in which I can stay focused on my treatment during the appointment time.
• I will agree to provide my specific location and contact phone number at the start of each appointment.
• Should a session be interrupted or disconnected for any reason, I agree to wait for my provider to make contact to reconnect and will accept the call or invitation to rejoin the session. Failure to reconnect may result in notification of emergency services as necessary, dependent on the situation.
• I understand that all documentation and storage of my protected health information will take place in the electronic health record utilized by Zumbro Valley Health Center.
• I understand that either my telehealth provider or I can discontinue the visit if the telehealth services are not adequate for my situation.
• I understand that I will be informed if individuals other than my telehealth provider are present in the room at the time of service, and appointments will be managed in a similar manner as in-clinic appointments.
• I understand that it is important to hold Telehealth sessions in a safe and private environment that allows for focusing on my care. If my provider believes the environment is not safe or not private (ie. In a public place, operating a vehicle, multiple distractions, etc) the session will be rescheduled.
• I understand that my provider can terminate telehealth therapy services if he/she determines that I would receive a greater benefit from in-clinic services. My provider will assist me in locating the appropriate resources and/ or making the transition to in-clinic services.

I understand the above and have had the opportunity to ask questions, which have been answered.*

Yes
No

Who is signing?*