103-21 Northern Blvd. Corona NY 11368
103-21 Northern Blvd. Corona NY 11368

Child Informed Consent for Online Therapy/Teletherapy Services

  • I the parent/guardian of the child consent to engage in online therapy/ teletherapy services with Integral Mental Health Counseling, PLLC

    I understand that online therapy/teletherapy includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using audio, video, or data communications.

    I understand that online therapy/teletherapy includes communication of my medical/mental information, both verbally and visually.

    I understand that I have the following rights regarding online therapy/teletherapy:

    1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.  
    2. The laws that protect the confidentiality of medical information also apply to online therapy/ teletherapy. As such, I understand that the information disclosed by me throughout my treatment is normally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are discussed in detail in the General Consent Form 
    3. I understand that despite reasonable efforts from Integral Mental Health Counseling, PLLC, there are risks and consequences from online therapy/teletherapy, including, but not limited to the possibility, that: the transmission of my information could be disrupted or destroyed by technical failures. 
    4. In addition, I understand that online counseling/teletherapy based services and care may not be as complete as face-to-face services. I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may improve, and/or in some cases may even get worse. 
    5. I understand that I may benefit from online therapy/teletherapy, but that results cannot be guaranteed or assured. 
    6. I accept that online therapy/teletherapy does not provide emergency services and I agree that if I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help; or call my primary care physician or psychiatrist. I am also aware that if I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Life line at 800-273-TALK (8255) for free 24-hour hotline support
    7. I understand that I am responsible for, providing the necessary computer, and/or telecommunications equipment with internet access for online counseling/ teletherapy sessions, as well as arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my online counseling/teletherapy session. 
    8. I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law. 


    - By signing this, I understand and agree to the terms in the teletherapy/online services Agreement.
    - By signing this, patient is giving verbal consent to receive teletherapy/online services with Integral Mental Health Counseling, PLLC

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