This form discusses telehealth services four your understanding and knowledge of what to expect. Please read, sign/accept and submit it before engaging in Telehealth Services.
  • Hidden
    MM slash DD slash YYYY
  • Definition of Telelhealth

    Telehealth involves the use of electronic communications to enable Rogue River Counseling clinicians to connect with individuals using live interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

    Clients Rights and Risks Regarding Telehealth

    1. The laws that protect the confidentiality of your personal information that have already been signed also apply to telehealth. Copy of our Office Policies and Notice of Privacy can be provided.

    2. You have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment.

    3. There are risks and consequences from telehealth including, but not limited to the possibility, despite reasonable efforts on the part of the counselor, that:

    • the transmission of personal information could be disrupted or distorted by technical failures.
    • the transmission of personal information could be interrupted by unauthorized persons, and/or the electronic storage of personal information could be unintentionally lost or accessed by unauthorized persons.

    4. Please note that there are certain situations, including emergencies and crises, that are inappropriate for audio-/video-/computer-based psychotherapy services. If you are in crisis or in an emergency, immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in your immediate area.

    5. Rogue River Counseling clinicians follow the State of Maryland COMAR Regulations for tele-health: 10.32.05 as well as their respective board regulations (BOPC/ACA or BSWE/NASW) and ethics. They have also received training to provide tele-health servic

    Format and Expectations

    Rogue River Counseling utilizes secure, encrypted HIPAA compliant audio/video transmission software to deliver telehealth via Zoom. Your therapist will provide you an email describing the login code and password for your session. Please test your devices use of zoom prior to your session. Some clients may have trouble with video or audio, and solving these issues can take up valuable therapy time. We cannot promise to be available to help with the technical side of the program.

    We at Rogue River feel that while Video sessions are adequate to the therapeutic process, they are not ideal. You may also feel the same way. Our preference is always to meet in person, however we are aware that circumstances may not always permit this. We will work together with you to make this the best therapeutic experience possible, however please understand there are limitations.

    Patient Consent to the Use of Telehealth:

    I have read and understand the information provided above regarding telehealth, have discussed it with my counselor, and all of my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained.

  • Privacy Notice Acknowledgement

  • I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.
  • Type your name below to sign this document.