Elizabeth Dear
Marriage and Family Therapist
Licensed Clinical Alcohol and Drug Counselor
527 Plumas Street
Reno, NV 89509
775-348-4696
Informed Consent for Telehealth
There may be times, the New Coronavirus 2019 being one of them, during our work together when it is best for us to conduct our sessions via telephone or video telehealth. These methods would be used only temporarily or for extenuating circumstances that override the value of face-to-face sessions. This format of psychotherapy requires a separate consent to treatment, as its risks and benefits differ from those of in-person therapy. Sessions would be offered via telephone, on a landline, if one is available, since mobile phones do not provide reliably confidential communication, or a HIPAA-compliant video conferencing method. We will each establish a private space that will not be interrupted and that protects your confidentiality. No one else will be listening to the conversation on either end unless that person is invited in as a participant and agrees to this consent. No recordings will be made unless we agree in writing to some exception. If we are meeting by video and the video fails, we will follow up by phone if problems persist for two minutes or more. At the beginning of each session I will ask for your location so that I am prepared to provide help in case of an emergency. If we are using a video service, I will contact you in advance to provide information on how to access the service.
I, ______________________________________, have read the above statement and consent to receiving psychotherapy services via telephone or videoconference.
Please provide preferred phone number: _______________________________________
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Client name (Print)
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Client Signature Date
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Parent or Guardian Signature (if client is a minor) Date
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Therapist Name (Print)
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Therapist Signature Date