Telehealth involves the use of electronic communications to enable Lutheran Counseling Services’ (LCS) mental health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data. I (the client and/or legal guardian) understand that I have the rights with respect to telehealth:

• I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health 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).
• I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
• I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that my personal information could be disrupted or distorted by technical failures or unauthorized persons. LCS utilizes secure, encrypted audio/video transmission software to deliver telehealth. The LCS counselor will use internet connections that are private and password protected to reduce the risk, and encourages the client to do the same.
• I understand that if my counselor believes I would be better served by another form of intervention (e.g., face-to-face services), I will be referred to a mental health professional associated with any form of psychotherapy, and that despite my efforts and the efforts of my counselor, my condition may not improve, and in some cases may even get worse.
• I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required. Should I become a danger to myself or others, I agree to call 911 or the National Suicide Prevention Lifeline: 1-800-273-8255.
• I understand that 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. The client and counselor will find a private and confidential space with a reliable internet connection for the duration of the telehealth counseling session.
• I will verify my identity and identify my current address/location to the counselor at the start of the session, and will provide a secondary contact method that can be used in case the telehealth platform connection is interrupted. Only the counselor and client will be present for the sessions unless it is first discussed privately between client and counselor for others to be present. All members in the session will be visible in the video frame.

I (the client and/or legal guardian) have read and understand the information provided above regarding telehealth, have discussed it with my counselor, and all of my questions have been answered to my satisfaction.

I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.

By my written or electronic signature below, I hereby state that I have read, understood, and agree to the terms of this document.

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