Art Therapy Telehealth Consent Form

Client Information

Full Name Date of Birth Address

I understand that art therapy services will be provided via telehealth technology. I understand the following:

I acknowledge understanding of confidentiality and its limits over telehealth.

I understand the potential risks of technology, disruptions, or unauthorized access in telehealth.

I understand that I can withdraw consent for telehealth at any time.

I have provided an emergency contact and understand crisis procedures have been explained to me.

Emergency Contact Name & Phone Questions / Concerns

Client Signature Date