Telemental Health Informed Consent Form

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I ____________________________________, hereby consent to participate in telemental health with James W. Pruett, PhD. of Bridgepath, Inc. for my psychotherapy. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client(s) who are located in different locations.

I understand the following with respect to telemental health:

▪ That I have the right to withdraw consent at any time without affecting my right to future care or services to which I would otherwise be entitled

▪ That if I am having suicidal or homicidal thoughts 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

▪ That the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to all telemental health unless an exception to confidentiality applies, i.e. mandatory reporting of child/elder/vulnerable adult abuse; danger to self or others; if I include mental/emotional health issues in a legal process

▪ That there will be no recording of any of the online sessions by anyone involved in the sessions and that all information disclosed within sessions and any written records regarding the sessions are confidential and may not be disclosed to anyone without written authorization, except where required by law

▪ That there are risks, benefits, and consequences associated with telemental health, including but not limited to - disruption of transmission by technological issues, interruptions, breaches of confidentiality by unauthorized persons, limited ability to respond to emergencies

▪ That should we encounter technical difficulties during a telemental health session we will attempt to restart the session and if we are unable to reconnect within 5 minutes, please call me at 704-577-5862 to discuss and re-schedule if necessary

▪ That Dr. Pruett may need to contact my emergency contact and/or appropriate authorities in case of an emergency; therefore, I agree to inform him of the address where I can be locatedat the beginning of each session and the name of a person whom he may contact on mybehalf in a life-threatening emergency only.

Your Signature

Emergency Contact Name

Address

Phone

I have read the information provided above and have discussed it with Dr. Pruett. I understand the information in this form and all my questions have been answered to my satisfaction.

Signature of Client/Parent/Legal Guardian

Date

Signature of Therapist

Date