Telehealth Informed Consent

Practice: Healing Path Behavioral Health LLC

I consent to receive behavioral-health services through telehealth when the provider determines telehealth is appropriate.

Telehealth may involve interactive audio/video technology. I understand potential benefits and limitations, including technology failure, privacy risks, interruptions, and limitations of remote assessment.

Before or at each session, I will provide my current physical location and a reliable method for contacting me if the connection fails. I understand that the practice may verify my identity and identify people present at either location.

Emergency plan: If an urgent safety issue occurs, the practice may contact emergency services or my emergency contact as permitted by law. For an immediate emergency, I should call 911 or go to the nearest emergency department.

Privacy: I agree to participate from a reasonably private location and to tell the provider if another person enters the session. The provider will use a secure telehealth platform and follow applicable privacy requirements.

I consent to telehealth.

I decline telehealth and request in-person care when available.

Patient/Parent/Guardian signature

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