Telehealth Counseling Consent Form

Client Information

Full Name Date of Birth Email Address Phone Number

Telehealth Counseling Consent

I hereby consent to engage in telehealth counseling services. I understand that telehealth refers to the provision of counseling services using telecommunication technology. I acknowledge that I have the option to withhold or withdraw consent at any time.

Confidentiality & Security

I understand that all laws protecting privacy and confidentiality also apply to telehealth counseling, and that all information disclosed during sessions will remain confidential. I acknowledge the potential risks related to technology and that security cannot be guaranteed.

Risks & Benefits

I recognize that telehealth counseling may have benefits including increased access and convenience, as well as risks such as possible technical difficulties or disruptions.

Emergency Procedures

I understand that telehealth is not appropriate for emergency situations. In case of an emergency, I will call 911 or go to the nearest emergency room.

Consent & Signature

Client Signature (type full name) Date