Consent for Treatment

ONLINE/PHONE THERAPY INFORMED CONSENT 

I hereby consent to engage in telemedicine (also referred to as online/phone therapy) with Eric Osterlind and associates. I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the electronic communication of my medical/mental health information, both orally and visually, to health care practitioners located in California or outside of California. 

I understand that I have the following rights with respect to telemedicine: I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment, nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. 

The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim or myself; and where I make my mental or emotional state an issue in a legal proceeding. 

This information is detailed in the Notice of Privacy Practices that I received. I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent. 

I accept that telemedicine does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. 

If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support. 

As with traditional in-person treatment, I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured. Advantages of telemedicine include, but are not limited to: increased access to a broader range of providers, elimination of transportation concerns such as access and cost, easier access for clients whose concerns around travel/anxiety/interaction would have prevented their access to services, reduced risk for medically fragile clients, increased comfort and familiarity for clients in their own environments. 

I understand that telemedicine-based services and care are different than face-to-face services. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic service arrangements can be made (e.g. face-to-face services) I will be referred to a psychotherapist who can provide such services in my area. 

Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy and that despite my efforts and the efforts of my psychotherapist, my condition may not be improved, and in some cases may even get worse. I understand that there are technological risks specific to telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. I understand that my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to “auto-remember” usernames and passwords, or use my work computer for personal communications; and that I am solely responsible for securing my end of our interaction. 

I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my telemedicine sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my telemedicine session, (4) a reliable high-speed internet connection.

I will maintain current local emergency contact information with my therapist. I have read and understood the information provided above. I have discussed it with my psychotherapist, and all of my questions have been answered to my satisfaction.