Yo, el padre/tutor del menor, doy mi consentimiento para participar en los servicios de terapia/teleterapia online con Integral Mental Health Counseling, PLLC Entiendo que la terapia/teleterapia online incluye consultas, tratamientos, transferencia de datos médicos, correos electrónicos, conversaciones telefónicas y educación mediante comunicaciones de audio, vídeo o datos.

Entiendo que la terapia/teleterapia online incluye la comunicación de mi información médica/mental, tanto verbal como visual.

Entiendo que tengo los siguientes derechos en relación con la terapia/teleterapia online:

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.

– Al firmar esto, entiendo y acepto los términos del Acuerdo de teleterapia/servicios online.
– Al firmar esto, el paciente está dando su consentimiento verbal para recibir servicios de teleterapia/online con Integral Mental Health Counseling, PLLC