Client Information

Full Name Date of Birth Email Address

Teletherapy Consent

I understand that online therapy (teletherapy) involves the use of electronic communications to enable therapists and clients to connect from different locations.

I consent to engage in online therapy sessions.

Confidentiality & Privacy

I have been informed of the risks to confidentiality unique to teletherapy, including potential disruptions or breaches beyond the therapist's control.

I understand and accept the confidentiality risks associated with online therapy.

Technology Requirements

I acknowledge that I am responsible for providing the necessary technology and a private space for sessions.

I acknowledge my responsibility for technology and session privacy.

Emergency Protocols

I agree to provide my location during each session and to follow therapist guidance in case of emergency.

I agree to the emergency protocols outlined above.

Signature