Purpose

I understand that telehealth involves the use of electronic communications to enable the delivery of substance abuse treatment services at a distance.

Nature of Telehealth

Counseling via video, audio, and/or digital communication.
The benefits and risks of engaging in telehealth have been explained to me.
All confidentiality protections and limitations apply as in face-to-face sessions.

Client Agreement

By signing below, I acknowledge that I understand the following:

I have the right to withdraw consent at any time.
There may be limitations to service delivery due to technology or other factors.
I am responsible for maintaining privacy on my end during telehealth sessions.
The laws that protect confidentiality apply to telehealth services.

I understand and agree to the above statements regarding telehealth substance abuse services.

Questions & Comments

If you have any questions or comments, please specify below:

Client Signature:

Date:

Provider Signature:

Date:

Substance Abuse Telehealth Consent Form

Purpose

Nature of Telehealth

Client Agreement

Questions & Comments