INFORMED CONSENT FOR TELEHEALTH

 The purpose of this form is to obtain your consent, either verbal or written to implement telehealth treatment for psychotherapy services provided by Leslie Davis, PsyD., LMFT

Purpose and Understanding

The purpose of telehealth therapy (online psychotherapy) services is to provide services to clients unable to attend face-to-face therapeutic services. Telehealth services are psychological services delivered by secure internet technology and other electronic means including interactive technologies such as audio, video, email, and other electronic communication. Telehealth services hold the same purpose of traditional in-person therapy including consultation and treatment and will largely consist of the same approaches and interventions.

It is a legal requirement for psychotherapist to practice in the state in which they are licensed. As such, you acknowledge that you are a resident of California and agree that when you participate in teletherapy sessions you will be physically present in California. You agree to inform the therapist if you are not present in California.

Identity Verification

All new clients will have to verify their age and identity by providing a scanned image of their driver’s license or other verifiable identification (i.e. governmental or other).

Technology

I will be utilizing ZOOM communications platform. You as the client will be responsible for securing their own computer or smart phone, internet, private location and headphones (optional if in private space).

Although precautions are taken to ensure that the information transmitted is secure, the possibility exists that the information transmitted in any electronic form could be intercepted by an unauthorized person/s.  Leslie Davis, PsyD, LMFT is not responsible for lapses in confidentiality that are in direct response to the client’s actions.

Disconnection Problems

If video services are not available due to an unplanned equipment or service malfunction, sessions will occur via telephone.

Recordings Are Prohibited

Clients are not allowed to make an audio or video recording of any portion of the session. Your therapist may engage in recordings of your session only if you are participating in couples therapy and have signed the consent for recording sessions. Sessions are not recorded without clients consent.

Risk of Harm

Online therapy is not a crisis based clinical service. Online psychotherapy may not be appropriate for clients with active suicidal or homicidal thoughts, or clients who are experiencing acute mental health problems, such as manic or psychotic symptoms. It is the responsibility of the client to inform Leslie Davis PsyD, LMFT if they are at risk of harm to self or others.

If through the intake evaluation or subsequent psychotherapy sessions, a client is deemed to be at risk of harm to self or to others, Leslie Davis, PsyD, LMFT will terminate the sessions, while providing alternative referrals/resources.

If a client who was not formerly at risk, should become at risk of such harm to self or others, they must immediately report it to Leslie Davis, PsyD, LMFT. In such cases, client may be referred to a traditional non-online counseling program or provider.

Payments

A form of reliable payment must be established before the first session occurs. Online payment arrangements must be made prior to appointment to begin session. If payment is not received on time, your session may be delayed or cancelled. 

No Shows or Late Cancellations

A full session fee will be charged to clients who do not show or who do not cancel their appointments within 24 hours of their scheduled appointment. If there are tech-issues, it is the client’s responsibility to contact Leslie Davis, PsyD, LMFT 866-824-4132 as soon as possible during you’re the first 15-minutes of your appointment to avoid paying the fee.

I hereby authorize Leslie Davis, PsyD, LMFT to utilize ZOOM as a means of psychotherapy. I understand the risks and limitations to online psychotherapy. By signing this consent, I agree to abide by its content.  I also attest to having read the INFORMED CONSENT FOR TELEHEALTH FORM above. 

If I should want a copy of this information sent to me or should I have any questions regarding this consent form I will contact Leslie Davis at: 866-824-4132.

OR by:

Mail: 1777 N. Bellflower Blvd., Suite 205, Long Beach, CA 90815