Informed Consent for Telemedicine Services

Organization: reSET Tomorrow

CLIENT INFORMATION

INFORMED CONSENT FOR TELEMEDICINE SERVICES

I understand that telemedicine/telehealth services involve the use of electronic communications, video conferencing, phone communication, and/or other technology between a client and provider who are not in the same physical location.

I voluntarily consent for myself and/or my child to participate in telemedicine services provided by reSET Tomorrow.

Telemedicine services may include:

 - Individual counseling
 - Family therapy
 - Group therapy
 - Behavioral health assessments
 - Case management
 - Care coordination
 - Crisis support
 - Parent support services
 - Follow-up appointments

Initials:_________

POTENTIAL BENEFITS OF TELEMEDICINE

I understand potential benefits may include:

 - Increased access to behavioral health services
 - Reduced travel time
 - Improved continuity of care
 - Increased scheduling flexibility
 - Ability to receive services in a familiar environment

Initials:_________

RISKS & LIMITATIONS OF TELEMEDICINE

I understand there are potential risks associated with telemedicine including, but not limited to:

 - Technical difficulties or interruptions
 - Internet or connectivity issues
 - Unauthorized access or confidentiality breaches
 - Reduced ability to respond immediately during emergencies
 - Limitations due to the inability to conduct in-person observations

I understand that telemedicine may not be appropriate for all situations and that in-person services may be recommended when clinically necessary.

Initials:_________

CONFIDENTIALITY & PRIVACY

I understand reSET Tomorrow will make reasonable efforts to protect confidentiality and utilize secure platforms whenever possible in compliance with HIPAA and applicable state and federal privacy laws.

I understand:

 - Sessions should take place in a private location whenever possible.
 - Recording of sessions by either party is prohibited unless written consent is provided.
 - Confidentiality laws apply to telemedicine services just as they do to in-person services.

Initials:_________

EMERGENCY PROCEDURES

I understand telemedicine services are not intended for emergency situations.

If there is a medical or psychiatric emergency, I agree to:

 - Call 911
 - Go to the nearest emergency room
 - Contact local crisis services

Initials:_________

TECHNOLOGY REQUIREMENTS

I understand I am responsible for:

 - Providing a working phone, tablet, or computer
 - Maintaining internet or cellular access
 - Logging into scheduled sessions on time
 - Providing updated contact information

I understand missed appointments or repeated connectivity issues may require rescheduling or transition to in-person services.

Initials:_________

RIGHT TO WITHDRAW CONSENT

I understand participation in telemedicine services is voluntary and I may withdraw consent at any time by notifying reSET Tomorrow in writing.
Withdrawal of consent will not affect my ability to receive other available services.

Initials:_________

CONSENT TO TREATMENT VIA TELEMEDICINE

By signing below, I acknowledge that:

 - I have read and understand this informed consent form.
 - I have had the opportunity to ask questions.
 - I understand the risks, benefits, and alternatives to telemedicine services.
 - I voluntarily consent to participate in telemedicine services through reSET Tomorrow.

SIGNATURES

By clicking the above button, I consent to be contacted by Reset Tomorrow and Webit, Inc. at any email address or telephone number I provide, including, without limitation, communications sent via text message to my cell phone or communications sent using an autodialer or prerecorded message. This acknowledgement constitutes my written consent to receive such communications. I agree and consent to any applicable Terms and Conditions of Use or Privacy Policy available on this website.