Informed Consent to Telemental Health

Basics of Tele-mental health:

  • You will need access to certain technological tools to engage in technology-assisted therapy
  • Telemental health has both benefits and risks, which you and your therapist will be monitoring
  • It is possible that receiving services by telemental health will turn out to be inappropriate for you, and that you and your therapist may have to cease work by telemental health
  • You can stop therapy by telemental health at any time for in-person therapy or a referral
  • You will need to participate in creating an appropriate space for your telemental health sessions
  • You will need to participate in managing technology failures and mental health emergencies
  • Fuller follows security best practices and legal standards in order to protect your health information, but you will als
    o need to participate in maintaining your own security and privacy

What is Telemental Health?

Telehealth service is ‘a health service, other than a telemedicine medical service, delivered by a health professional licensed, certified, or otherwise entitled to practice in this state and acting within the scope of the health professional’s license, certification, or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology.’

Services delivered via telehealth rely on electronic, internet-based technology tools. Dr. Fuller uses a HIPAA compliant service, Ring Central, which includes video-conferencing software, text messaging, and a virtual phone system. You will need access to reliable internet service and either a smartphone or computer with a video camera and speaker in order to engage in telemental health work with Dr. Fuller.  If you have any questions or concerns about the above tools, please discuss them with Dr. Fuller or her staff to address their risks, benefits, and specific application to your treatment.

Benefits and Risks of Telemental Health

Receiving services via telemental health allows you to receive services:
  • at times or in places where the service may not otherwise be available.
  • in a fashion that may be more convenient and less prone to delays than in-person meetings.
  • when you are unable to travel to the therapist’s office.

The unique characteristics of telemental health may also help some people make improved progress on health goals that may not have been otherwise achievable without telemental health.

Receiving services via telemental health has the following risk of:
  • technical failures, such as unstable internet connection or sudden failures related to computers, smartphone or local power services.
  • limiting your therapist’s ability to directly intervene in crisis or emergencies.
  • potential breach of confidentiality as Cloud-based service personnel, IT assistants, and malicious actors (“hackers”) may have the ability to access your private information that is transmitted or stored in the process of telemental health-based service delivery.
  • Interruptions may disrupt services at important moments, and your therapist may be unable to reach you quickly or using the most effective tools.

Assessing Telemental Health’s Fit for You

Although it is well validated by research, service delivery via telemental health is not a good fit for every person. Dr. Fuller will continuously assess if working via telemental health is appropriate for your case. If it is not appropriate, Dr. Fuller will help you find in-person therapists with whom to continue services. You have right to stop receiving services by telemental health at any time without any repercussions. Please talk to Dr. Fuller or her staff if you find the telemental health platform so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the telemental health medium seems to be causing problems in receiving services.

Your Telemental Health Environment

You will be responsible for creating a safe and confidential space during sessions at the address below. You should use a space that is free of other people. It should also be difficult or impossible for people outside the space to see or hear your interactions with your therapist during the session. If you are unsure of how to do this, please ask for assistance. If you are at a location other than the one disclosed below please tell Dr. Fuller at the start of the session.

Telemental Health Etiquette

It is important to consider several items for best practice in terms of etiquette with tele-mental health. It is important for both the client and the therapist minimize distractions during the session. This means being in a confined space without animals or other distractions.  Please also be considerate of the other person’s field of view and arrange the screen so that you can be seen from the chest up with adequate lighting.

Our Communication Plan

After scheduling, you will receive a meeting invitation by email with information for how to access our online secure platform for tele-health. At our first session, we will verify telephone contact information to use in the case of technology failures. If you need to communicate between sessions, please contact Margarita by email or phone.  Please note that all email or text messages you exchange with Dr. Fuller or her staff become a part of your health record. Text messages are for scheduling only.  Therapy by phone is not ideal and not allowed for ongoing therapy, but only in the case of some kind of technical failure in the use of video conferencing. If you prefer not to receive text messages or emails, please notify your therapist at your first meeting or through the initial session form.

Our Safety and Emergency Plan

As a recipient of telemental health-based services, you will need to participate in ensuring your safety during mental health crises or medical emergencies. This will include providing an emergency contact and permission to communicate with this person about your care in the case of an emergency.  

Your Security and Privacy

Dr. Fuller has been thoroughly trained in the use of telehealth and has selected HIPAA compliant service providers to adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged.  However, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with your therapist, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that your therapist has supplied for communications.

Please do not record video or audio sessions without your therapist’s consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. Your therapist may record sessions for training purposes as outlined in the general treatment consent.  

Consent to Telemental Health Agreement

Sign the form via Adobe Sign here.

This consent is in addition to the general consent for treatment, which must be read and signed by all participating adults or on behalf of all participating minors. Please also see our general information for new clients and Notice of Privacy Practices on our website for additional information.

My signature below indicates I understand the risks of tele-mental health and will comply with the above guidelines. I understand this consent is for online therapy and is in addition to our traditional consent to treatment, information for new clients and notice of privacy practices.

Management Plan for Technological issues or Emergencies for Telemental Health

Plan for Technological Difficulty or Disconnection

If you are participating in a telemental health session and are disconnected follow these steps:

  1. Troubleshoot your internet connection and reattempt to connect via Ring Central.
  2. Communicate with the other meeting participants via chat, text, email or phone.  The first method to communicate in this preference is text messaging. If no response, phone or email can be used to communicate. Your therapist will include their direct number in the first meeting or through email to you.
  3. If the Ring Central platform is not viable for some reason, the second method is to utilize zoom. The web address is https://us02web.zoom.us/j/6156522316Your therapist will make sure you have the correct web address when you discuss this plan.
  4. If neither Ring Central nor zoom are viable options, therapy may proceed via telephone.

If you are having difficulty with technology or connection issues, please discuss them with the therapist to troubleshoot or generate alternate solutions.

Plan for meeting delays, tardiness and cancellation fees

Your therapist will make every effort to be timely. In the event that ether person is waiting for longer than 5 minutes please send a text message (or email) saying you are present, since it is possible there is simply a technical error.  Either party should call after waiting 10 minutes, if not sooner. 

  • If the client has waited 15 minutes, made a text at or before 5 minutes and a phone call at or before 10 minutes, then the client is dismissed from cancellation fees after waiting 15 minutes.
  • If the client is not present after a text at or before 5 minutes or a phone call at or before 10 minutes, then the cancellation fee will apply at 15 minutes.
  • Please speak to your therapist for special circumstances.

Cancellation fees will apply to all sessions not cancelled with 24 hours’ notice for non-emergencies.

Crisis Management Plan for Emergencies:

Telemental Health presents common risks not present with “in person” therapy.  The following steps are designed to ensure the clients safety as much as possible.

  1. Physical Address: It is important for the therapist to know the physical address where you are participating in tele-mental health in the unlikely incident of an emergency. Please include the primary physical location where you will be when participating in technology assisted therapy.
  2. A Client Support Person for Emergencies. Please include below the name, contact information and relationship of an emergency contact. This will serve as a release of confidential information if a situation arises that the therapist deems a crisis.  Please inform your emergency contact that you are participating in tele-mental health therapy and have listed them as your emergency contact.  
  3. Local Emergency Contact. If there is an emergency or crisis and we are not able to contact your primary support person, we will contact local emergency personnel. Please list the name of the closest or preferable hospital or emergency room in your area. 
  4. If there is a crisis or emergency outside of a session, please know that we are an outpatient mental health organization and are not equipped for emergencies. If you are ever experiencing an emergency, including a mental health crisis, please call and indicate the situation clearly in your message. We are not equipped for emergencies and will respond within 2 business days.

In the event of a psychiatric emergency: Dial 911, go to your local emergency room or request the Crisis Intervention Team at the MHMRA Neuropsychiatric Center by calling 713.970.7070. 

My signature indicates I understand the above management plans, will comply with these guidelines, and may seek clarification or alter the agreement at any time in collaboration with my therapist.