TELEHEALTH INFORMED CONSENT

Effective Date: June 1, 2026

I. What Is Telehealth?

Telehealth is the delivery of psychiatric and other mental health and medical services using interactive audio and visual electronic systems where the clinician and the patient are not in the same physical location. Your provider offers telehealth services when clinically appropriate using HIPAA-compliant platforms, including Zoom. Zoom meets or exceeds all requirements of HIPAA as a business associate and agrees to be responsible for keeping all client information private and to immediately report any breach of protected health information. The interactive electronic systems used incorporate network and software security protocols to protect the confidentiality of patient information and audio/visual data, including measures to safeguard data against intentional or unintentional corruption.

Please note that video conferencing is not the same as an in-person appointment. Assessment measures completed over telehealth may not have been validated for video administration. Your provider believes that telehealth services are appropriate and that you would benefit from their use despite their risks and limitations. While you may expect anticipated benefits, no specific results can be guaranteed or assured.

II. Potential Benefits of Telehealth

• Increased accessibility to care
• Patient convenience
• Ability to obtain expertise of a distant clinician

III. Potential Risks of Telehealth

• Information transmitted may not be sufficient (e.g., poor video resolution) to allow for appropriate clinical decision-making.
• Delays in evaluation and treatment could occur due to equipment deficiencies or failures.
• Security protocols can fail, causing a breach of privacy of confidential medical information, including interruptions and unauthorized access.
• In rare cases, a lack of access to all the information available in a face-to-face visit could result in the omission of care involving other health problems or possible adverse drug interactions.

IV. Confidentiality and Privacy

All laws and regulations protecting the privacy and confidentiality of your medical information apply equally to telehealth sessions as they do to in-person sessions. All state rules and regulations that apply to in-person care also apply to telehealth. Medical information transmitted electronically will be encrypted during transmission and stored only by your provider or a service provider they select. The dissemination of any personally identifiable images or information from telehealth communications to researchers or other health care providers will not occur except as required by federal or California state law.

V. Jurisdiction

By signing this form, you submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telehealth services provided by your provider and their staff will be brought solely and exclusively in California state superior courts. You also agree that the interpretation of this consent will be governed exclusively by the laws of California.

VI. Licensing and Emergency Care

Your provider is located in and licensed by the State of California. Your provider may not be able to prescribe medications and/or may not be able to assist you in an emergency situation when you are located in another state or country.

• If you require emergency care: Call 911 or proceed to the nearest hospital emergency room.
• If you are having suicidal thoughts or plans to harm yourself: Call the 988 Suicide and Crisis Lifeline by dialing or texting 988, available 24 hours a day, 7 days a week. You may also call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

VII. Your Rights

1. I understand that all laws protecting the privacy and confidentiality of my medical information apply to telehealth.
2. I understand that all state rules and regulations that apply to in-person sessions also apply to telehealth sessions.
3. I understand that I have the right to withhold or withdraw my consent for the use of telehealth at any time during the course of my care. Withdrawal of consent will not affect any future care or treatment unless it becomes logistically impossible to continue care, in which case referrals will be made.
4. I understand that my provider also has the right to withhold or withdraw their consent for the use of telehealth at any time during the course of my care, and if they determine that telehealth is no longer appropriate, they will work with me to identify an alternative provider for in-person care.
5. I understand that I may direct questions about telehealth to my provider at any time.
6. I understand that this consent will last for the duration of my relationship with my provider, including any additional video sessions for testing, treatment, or feedback purposes.

VIII. My Responsibilities

1. Location: I will inform my provider at the start of each session of my physical location and will not join from a state where my provider is not licensed without prior notice. I understand my provider may need to terminate the session if I join from an unlicensed location. Exceptions may be made for emergencies, crises, or clinically necessary sporadic visits while traveling to ensure appropriate continuity of care. I will join from a safe, quiet, and private location and will not attend sessions while driving or operating heavy machinery. I understand that in order for the session to run smoothly, I should be in a place with limited interruptions.
2. Equipment: I will ensure the proper configuration and functioning of my electronic equipment prior to each session. My device must have a working camera and audio input so that my provider can see and hear me in real time.
3. Recording: I will not record any telehealth session without explicit written consent from my provider. I understand that my provider will not record any session without my written consent.
4. Other persons present: I will inform my provider at the start of each session if any other person can hear or see any part of our session. My provider agrees to inform me and obtain my consent if another person is present during the consultation for any reason.
5. Connection issues: If I lose my connection during a session, I will immediately attempt to log back into the Zoom waiting room. If the audio is not complete and clear, I will attempt to notify my provider or contact the office to schedule a new appointment.
6. Safety planning: I agree to work with my provider to develop a safety plan in the event of a crisis during our sessions.
7. Minor patients: If my child is the patient, I agree to monitor and ensure their safety during video sessions and to remain nearby in case of emergency.

IX. Scheduling Telehealth Sessions

If you decide that the benefits of telehealth outweigh the risks, you may request telehealth sessions when scheduling follow-up appointments. If your provider agrees, you will be scheduled for a telehealth session and sent an internet link with instructions to log in immediately prior to your scheduled appointment time.

X. Changes to this Notice

This document was last revised: June 1, 2026. It supersedes all prior versions.

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XI. Acknowledgment and Agreement

By signing this form, I certify that:

• I have read, or had read and explained to me, the contents of this form.
• I fully understand its contents, including the risks and benefits of telehealth services.
• I have been given the opportunity to ask questions and that any questions have been answered to my satisfaction.
• I agree to participate in telehealth and/or telemedicine services with my provider.

Patient (or Legal Guardian if patient is a minor)

Signature: ___________________________________________

Date: ___________________________________________

Printed Name: ___________________________________________

Relationship (if signing on patient's behalf): ___________________________________________