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Telehealth Agreement Form

  • Journey Assistance Counseling, LLC

    (240) 507-2634


    The purpose of this form is to obtain your consent to participate in telemental health, which involves counseling by phone, video, or secure online email portal.

    Participating in telehealth sessions is based on compliance with the following:
    • If we are connecting by video, I will send you a link to sign in to my secure and HIPAA-compatible video platform. You don't need to set up an account of any kind in advance. It is OK to "arrive" early -- I will connect with you at the time of the session.
    • I will be in a private location where I am alone in the room. You also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality. If you choose to be in a place where others can hear you, I cannot be responsible for your confidentiality.
    • At the start of the session, I may verify your location (street address). This enables me to send help, if needed, and to verify that you are in-state. I can only provide therapy to you while you are in the state where I am licensed (Maryland). If I do not ask, please be sure to tell me if you are not at your home.
    • Do not invite others to join us for any part of the session without discussing this with me in advance.

    If we lose our video connection during our session, please quit and restart your search engine (or computer), and sign in again to the video platform. If you can't reconnect, call my office number (see first page of this agreement), If I do not hear from you within 5 minutes, I will call and email you. I will remain available during the time of our scheduled session, so we can reconnect and continue, if possible.

    If the disconnection is due to my service or equipment, I will not charge you for the session, or will prorate it for what time we talk. If the disconnection is due to your service or equipment, you will be charged in full for the session (not just a copayment).

    To ensure the security of the telehealth sessions we will I utilize video software and hardware tools that adhere to security best practices and legal standards for the purposes of protecting your privacy. Addionally, please comply with the following security requirements:
    • It is not recommended that you communicate using a public wireless network.
    • You represent that you are not using someone else's device or your employer's computer, since employers have the right to monitor their equipment and networks, which could compromise your privacy.
    • You have the sole responsibility for security and privacy of your devices, equipment, and internet connection.
    No sessions will be recorded by me, and the telehealth platform provider. Please note that recording or screenshots of any kind of any session are not permitted, and are grounds for termination of the client-therapist relationship.

    Must be made prior to our session or the day of the session. I will charge your credit card on file on the session date. If you have insurance and I am on your insurance provider list, I will bill insurance on your behalf, but you remain responsible for any portion they do not pay.

    Phone/video sessions are treated as in-office sessions when it comes to late cancellations and no-shows -- 24-hour advance notice is required, otherwise you will be charged the applicable fee.

    Please note that everything in our informed consent that you signed, including all the confidentiality exceptions, still applies during phone/video sessions.

    By signing below, you agree that you have read and understand all of the above. You agree and understand the limitations associated with participating in telehealth sessions and consent to attend sessions under the terms described in this document.
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