Consent for Telehealth Therapy Sessions

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE
Telehealth by SimplePractice is the technology service we will use to conduct telehealth
videoconferencing appointments. It is simple to use and there are no passwords
required to log in. By signing this document, I acknowledge:

1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of
   an emergency, I will use a phone to call 911.
2. Though my therapist and I may be in direct, virtual contact through the Telehealth
   Service, neither SimplePractice nor the Telehealth Service provides any medical
   or healthcare services or advice including, but not limited to, emergency or
   urgent medical services.
3. The Telehealth by SimplePractice Service facilitates videoconferencing and is
   not responsible for the delivery of any healthcare, medical advice or care.
4. I do not assume that my therapist has access to any or all of the technical
   information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my therapist to have any of this information in the Telehealth by SimplePractice Service.
5. To maintain confidentiality, I will not share my telehealth appointment link with
   anyone unauthorized to attend the appointment.

CONSENT FOR TELEHEALTH THERAPY SESSIONS

1. I understand that my counseling therapist wishes me to engage in telehealth
   therapy sessions.
2. My counseling therapist explained to me how the video conferencing technology
   that will be used to affect such visits will not be the same as a direct
   client/therapist visit due to the fact that I will not be in the same room as my
   therapist.
3. I understand that a telehealth session has potential benefits including easier
   access to care and the convenience of meeting from a location of my choosing.
4. I understand there are potential risks to this technology, including interruptions,
   unauthorized access, and technical difficulties. I understand that my therapist or I
   can discontinue the telehealth visit if it is felt that the videoconferencing
   connections are not adequate for the situation.
5. I have had a direct conversation with my therapist, during which I had the
   opportunity to ask questions in regard to this procedure. My questions have been
   answered and the risks, benefits and any practical alternatives have been
   discussed with me in a language in which I understand.

©2024 Path of Hope Counseling, LLC 

pathofhopeoregon.com

rachel@pathofhopeoregon.com

Physical: 1126 Gateway Loop, Suite 110, Springfield (by appointment)

Mailing: 1863 Pioneer Parkway East #610

Springfield, OR  97477

Phone: (541) 357-9523

Fax: (855) 335-8228