TELE-HEALTH INFORMED CONSENT

I consent to engaging in tele-health with Ellie Mental Health as a part of the therapy process and my treatment goals. I

understand that tele-health psychotherapy may include mental health evaluation, assessment, consultation, treatment

planning, and therapy. Tele-health will occur primarily through interactive audio, video, telephone and/or other

audio/video communications.

I understand I have the following rights with respect to tele-health:

1. I have the right to withhold or remove consent at any time without affecting my right to future care or treatment, nor

endangering the loss or withdrawal of any program benefit to which I would otherwise be eligible.

2. The laws that protect the confidentiality of my personal information also apply to tele-health. As such, I understand

that the information released by me during the course of my sessions is generally confidential. There are both

mandatory and permissive exceptions to confidentiality including but not limited to reporting child and vulnerable adult

abuse, expressed imminent harm to oneself or others, or as a part of legal proceedings where information is

requested by a court of law. I also understand that the dissemination of any personally identifiable images or

information from the tele-health interaction to other entities shall not occur without my written consent.

3. I understand that there are risks and consequences from tele-health including but not limited to, the possibility,

despite reasonable efforts on the part of Ellie Mental Health, that the transmission of my personal information could be

disrupted or distorted by technical failures and/or the transmission of my personal information could be interrupted by

unauthorized persons. In addition, I understand that tele-health based services and care may not be as complete as

in-person services. I understand that if my therapist believes I would be better served by other interventions I will be

referred to a mental health professional who can provide those services in my area. I also understand that there are

potential risks and benefits associated with any form of mental health treatment, and that despite my efforts and

efforts of my therapist, my condition may not improve, or may have the potential to get worse.

4. I understand that I may benefit from tele-health services, but that results cannot be guaranteed or assured. I

understand that the use of Skype, FaceTime, GoToMeeting, and Google audio/video systems are not 100% secure

and may have issues with wifi connectivity. All attempts to keep information confidential while using these systems will

be made but a guarantee of 100% confidentiality cannot be made with inherent issues with these communication

systems. Signing this form shows an awareness of these issues and a decision by this client to use these systems for

tele-health services. I will not hold Ellie Mental Health or its staff liable for gathering or use of client information by

these service providers.

5. I understand I have the right to access my personal information and copies of case notes. I have read and

understand the information provided above. I have discussed these points with my therapist, and all of my questions

regarding the above matters have been answered to my approval.

6. By signing this document, I agree that certain situations including emergencies and crises are inappropriate for

audio/video/computer based psychotherapy services. If I am in crisis or in an emergency I should immediately call 911

or go to the nearest hospital or crisis facility. By signing this document, I understand that an emergency situation may

include thoughts about hurting or harming myself or others, having uncontrolled psychotic symptoms, if I am in a life

threatening or emergency situation, and/or if I am abusing drugs or alcohol and are not safe. By signing this

document, I acknowledge I have been told that if I feel suicidal I am to call 911, local county crisis agencies or the

National Suicide Hotline at 1-800-784-2433.